chap 9 High-Risk intra

A client, 42 weeks' gestation, is admitted to the labor and delivery suite with a diagnosis of acute oligohydramnios. The nurse must anticipate seeing which of the following? SATA 1. variable FHR decelerations 2. late FHR decelerations 3. oliguria 4. tachysystole

1, 2

A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated or considered high risk at this time? SATA 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.

1, 2

The nurse in the obstetrician's office is caring for four prenatal clients with singleton pregnancies at 25 weeks' gestation. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? Select all that apply. 1. 38-year-old in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation. 3. 30-year-old whose baby has a two-vessel cord. 4. 26-year-old with a history of long menstrual periods. 5. 22-year-old who smokes 2 packs of cigarettes every day.

1, 2, and 5 are correct. 1. This client is high risk for PTL because she is over 35 years of age and in an abusive relationship. 2. A previous preterm delivery places a client at increased risk of preterm labor. 5. A woman who smokes cigarettes is at high risk for preterm labor.

A client's membranes ruptured spontaneously while the nurse was at the bedside. . Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. 1. Breech presentation. 2. Vertex presentation at Station -3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie.

1, 2, and 5 are correct. 1. When a baby is in the breech presentation, there is increased risk of prolapsed cord. 2. The presenting part is floating, which increases the risk of prolapsed cord. 5. When a baby is in the transverse lie, there is increased risk for prolapsed cord.

A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartum complications? SATA 1. Respiratory distress 2. Jaundice 3. withdrawal 4. PDA 5. Microencephaly

1,3, 4, 5 Jaundice lower incidence with heroine or cocaine

A 40-week-gestation woman has received misoprostol for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.

1. A common side effect of Cytotec is diarrhea and labor contractions are often first felt in the back.

A client at 38-week-gestation is in labor and delivery with a painful, board-like abdomen. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.

1. A fetal heart check is the appropriate assessment.

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? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.

1. Because the client will have a cesarean section with anesthesia, the woman should be taught coughing and deepbreathing exercises for the postoperative period.

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.

1. Fundal heights increase during pregnancy approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour. When a placenta abrupts, it separates from the uterine wall. As a result, a pool of blood appears behind the placenta. The pool of blood takes up space leading to an increase in the size of the uterus. The fundal height increases as the uterine size increases

The physician has ordered oxytocin (Pitocin) for induction for 4 clients. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.

1. Induction is contraindicated in transverse lie.

A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone 4. Oxytocin

1. The nurse must have calcium gluconate in the client's room.

A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultates the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. 2. Notify the health care provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask.

1. The nurse should assess the fetal heart and the maternal pulse simultaneously.

The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? 1. Risk for impaired skin integrity. 2. Risk for body image disturbance. 3. Risk for impaired parenting. 4. Risk for ineffective sexuality pattern.

1. The woman is at risk of impaired skin integrity.

A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.

1. These are the classic signs of water intoxication.

The nurse is caring for a laboring woman who is 42 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? 1. Late decelerations. 2. Hyperthermia. 3. Hypotension. 4. Early decelerations.

1. This baby is high risk for the development of late fetal heart decelerations.

The nurse is admitting a 38-week-gestation client in labor. The nurse is unable to find the fetal heartbeat with a Doppler. Which of the following comments by the nurse would indicate that the nurse is in denial? 1. "I'll keep trying until I find the heartbeat." 2. "I am sure it is the machine. If I change the battery, I'm sure it will work." 3. "I am so sorry. I am not able to find your baby's heartbeat." 4. "Sometimes I really hate these machines."

1. This is an example of the stage of denial.

A nurse has been assigned to circulate during the cesarean section of triplets. Which of the following actions should the nurse take before the birth of the babies? Select all that apply. 1. Count the number of sterile sponges. 2. Document the time of the first incision. 3. Notify the pediatric or neonatal staff. 4. Perform a sterile scrub on the client. 5. Assemble the sterile instruments.

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The fetal heart rate pattern of a client in active labor shows moderate variability with late decelerations. The nurse makes which of the following interpretations of the pattern? 1. category I pattern requiring tocolytic medication administration 2. category II pattern requiring lateral positioning, oxygen administration via face mask, and intravenous fluid bolus 3. category III pattern requiring lateral positioning, oxygen administration via face mask, intravenous fluid bolus, and amnioinfusion 4. category IV pattern requiring immediate termination of labor

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The nurse is monitoring a client in labor with an obstetrical history of G2 P1001, at 41 weeks' gestation. See the nurse's cervical and FHR assessments from 1200 to 2200below. 1200 cervix 4cm 80% effaced -3 station FHR 124 bpm with moderate variability 1700 cervix 6cm 90% effaced -3 station FHR 120 bpm with moderate variability 2200 cervix 8cm 100% effaced -3 station FHR 124 bpm with moderate variability based on the assessments which of the following should the nurse conclude? 1. labor is progressing well 2. the client is likely carrying a macrosomic fetus 3. the fetus is not tolerating labor 4. the client will be in second stage in about five hours.

2

A physician writes the following order—Administer penicillin G, 5 million units IV x1 then 2.5 million units q 4h until delivery- for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal bacteria at 36 weeks' gestation. Which of the following is a rationale for this order? 1. The client is at high risk for chorioamnionitis. 2. The baby is at high risk for neonatal sepsis. 3. The bacterium is sexually transmitted. 4. The bacterium causes puerperal sepsis.

2. Babies are susceptible to neonatal sepsis from vertical transmission of the bacteria.

In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? 1. Placental abruption. 2. Meconium-stained fluid. 3. Polyhydramnios. 4. Late decelerations.

2. It would be appropriate for a health care practitioner to order an amnioinfusion when a client's amniotic fluid is meconium stained.

A physician has notified the labor and delivery suite that four clients will be admitted to the unit. The client with which of the following clinical findings would be a candidate for an external version? 1. +3 station. 2. Left sacral posterior position. 3. Flexed attitude. 4. Rupture of membranes for 24 hours.

2. LSP position is a breech presentation. It may be appropriate for a physician to perform an external version prior to this delivery.

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 120 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate.

2. Maternal temperature is the highest priority.

The nurse is caring for a client at 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick count assessments.

2. Positive fetal fibronectin levels are seen in clients who deliver preterm.

A nurse is monitoring the labor of a client who is receiving IV oxytocin at 10 milliunits per minute. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4°F. 39.1

2. The baseline fetal heart rate has dropped over 20 bpm. This finding warrants that the oxytocin be stopped.

A client's assessments reveal that she is 4 cm dilated and 90% effaced with a fetal heart rate tracing showing recurrent late decelerations, minimal variability and contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.

2. The nurse's goal at this point must be the delivery of a healthy baby.

The nurse observes a new staff member caring for an eclamptic client following a seizure. Which of the following actions by the staff member indicates an understanding of eclampsia? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and headboard. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2. The side rails of an eclamptic client's bed should be padded.

A client with an internal fetal spiral electrode in place has just received IV narcotic for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Minimal variability. 4. Accelerations after contractions.

3. Absent variability would be expected as a result of Stadol administration.

The nurse is caring for two post-cesarean section clients in the post-anesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. Clients with spinal anesthesia complain of nausea and vomiting

3. Epidurals do not fully sedate the motor nerves of the client. Epidural clients are capable of moving their lower extremities even when fully pain free.

5 minutes ago, the health care practitioner performed an amniotomy on a client at 40 weeks' gestation. The client's obstetrical history is G3 P1011. The fetus was at -4 station, and ROP position at the time of the amniotomy. The fetal heart rate is 140 with a prolonged decelerations. The fluid is green tinged . The nurse concludes that which of the following situations is present at this time? 1. The fetus is post-term. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.

3. It is likely that the cord is prolapsed because the amniotomy was performed when the presenting part was not yet engaged and because variable decelerations are seen on the FH monitor.

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3. Low platelets are consistent with the diagnosis of HELLP syndrome.

A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes? 1. Intravenously. 2. Orally. 3. Endocervically. 4. Intrathecally.

3. Prepidil is administered endocervically.

A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.

3. The client's bladder should be palpated.

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? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.

3. The most common difference between placenta previa and placenta abruption is the absence or presence of abdominal pain.

A 35-year-old client with pre-eclampsia is being induced with oxytocin. She is contracting every 3 min × 30 seconds. Suddenly the woman becomes dyspneic and cyanotic, and begins to begins to have chills. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.

3. The nurse's priority action is to administer oxygen.

A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? 1. Obtain an order from the obstetrician to prepare the client for cesarean delivery. 2. Obtain an order from the obstetrician to administer intravenous ampicillin during labor and the immediate postpartum. 3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. 4. Obtain an order from the pediatrician to place the baby in isolation after delivery.

3. Within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG.

Four women request to labor in the hospital bathtub with waterproof fetal heart rate monitoring devices. In which of the following situations is the procedure contraindicated? Select all that apply. 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with meconium-stained fluid. 5. Woman with a temperature of 100.4F 38C

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A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 150 with moderate variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Dinoprostone has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.

4. A contraction frequency of 1 minute, even with a short duration, would warrant the removal of the medication.

An anesthesiologist informs the nurse that a woman scheduled for cesarean section will have the procedure under general anesthesia with postoperative patient-controlled analgesia rather than under continuous epidural infusion. Which of the following would warrant this decision? 1. The woman has a history of drug addiction. 2. The woman is allergic to morphine sulfate. 3. The woman is a 13-year-old adolescent. 4. The woman has had surgery for scoliosis.

4. A history of scoliosis surgery is a contraindication for epidural anesthesia.

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.

4. A serum magnesium level of 9 g/dL is dangerously high. The health care practitioner should be notified.

A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop her infusion. 2. Give her oxygen via face mask 3. Change her position. 4. Monitor the client's labor

4. It is appropriate to monitor the woman's labor.

A woman is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. Station -2. 2. 38 weeks' gestation. 3. Reactive NST. 4. Previous cesarean section.

4. Previous cesarean section is a contraindication for external version.

A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin 2. Methylergonovine 3. Betamethasone 4. Terbutaline

4. Terbutaline (Brethine) is a smooth, muscle-relaxing agent. It would be administered prior to an external version.

A nurse administers magnesium sulfate via infusion pump to a laboring client who has pre-eclamptic with severe features. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output is 30 mL/hr. 3. Respiratory rate is 16 rpm. 4. Client has no grand mal seizures.

4. The absence of seizures is an expected outcome related to magnesium sulfate administration.

A client, G3 P2002, has just had an external version. The nurse monitors this client carefully for which of the following? 1. Decreased urinary output. 2. Elevated blood pressure. 3. Severe occipital headache. 4. Variable fetal heart decelerations.

4. The nurse should monitor the client carefully for variable fetal heart decelerations.

A 40-week-gestation client has an admitting platelet count of 90,000 cells/mm3 and a hematocrit of 29%. Her lab values 1 week earlier were platelet count 200,000 cells/mm3 and hematocrit 37%. Which additional abnormal lab value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. (AST) 4. Elevated alanine transaminase (ALT).

4. The nurse would expect to see an elevated ALT.

A nurse is triaging four clients on the labor and delivery unit. Which of the following actions should be a priority for nursing care? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia without severe features 4. Check the fetal heart rate of a client who just ruptured membranes.

4. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency.

Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? 1. +3 pitting edema and pulmonary edema. 2. Epigastric pain and systemic jaundice. 3. +4 deep tendon reflexes and clonus 4. Oliguria and elevated specific gravity.

Epigastric pain and jaundice are re- flective of hemolysis of red blood cells and of severe liver damage. These symptoms should make the nurse sus- pect HELLP syndrome The test taker must be able to discriminate between symptoms of severe preeclampsia and HELLP syn- drome. If the nurse remembers what each of the letters in HELLP stands for, he or she can determine which of the responses is correct. Bilirubin is the by- product of RBC breakdown and bilirubin is metabolized in the liver.

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions are essential for the nurse to perform? SATA 1. Put the client in the knee-chest or Trendelenburg position. 2. Assess the fetal heart rate by palpating the cord 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.

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A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 milliunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.

1. An order for oxytocin administration should be questioned.

To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which of the following medications? 1. Antacids. 2. Tranquilizers. 3. Antihypertensives. 4. Anticonvulsants.

1. Antacids are routinely administered presurgically to cesarean section clients.

A client with an obstetrical history of G2 P1001 has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 145bpm with moderate variability, contractions every 5 minutes × 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take? 1. Check dilation and effacement. 2. Prepare the client for surgery. 3. Place the bed in Trendelenburg position. 4. Check the biophysical profile results.

1. It is appropriate for the nurse to assess the client's dilation and effacement.

A baby is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. LMA (left mentum anterior). 2. LSP (left sacral posterior). 3. Dorso-superior 4. ROP (right occiput posterior).

1. LMA position is consistent with that information.

A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sadness. 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.

1. The nurse would expect the client to be crying and sad.

A woman in active labor received Nubain (nalbuphine hydrochloride) 14 mg IV for pain relief. One half hour later her respirations are 8 rpm. The nurse reports the respiratory rate to the physician. Which of the following medications would be appropriate for the physician to order at this time? 1. Narcan (naloxone). 2. Reglan (metoclopramide). 3. Benadryl (diphenhydramine). 4. Vistaril (hydroxyzine).

1. The nurse would expect to administer Narcan to the client.

A woman, 32 weeks' gestation, contracting every 3 min × 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.

1. The urinary output should be carefully monitored.

A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes +1. 4. Blood pressure 140/90.

1. This client has likely developed disseminated intravascular coagulation (DIC). The nurse should watch for pink-tinged urine.

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip.

The nurse notes a pattern of tachysystole during a client's oxytocin induction. The nurse turns off the oxytocin infusion. Which of the following outcomes indicates that the nurse's action was effective? 1. contraction intensity moderate 2. contraction frequency every 3 minutes 3. fetal heart rate 140 bpm 4. fetal attitude flexed

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While waiting to conclude the third stage of labor, the obstetrician states that a client has placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. hypertension 2. hemorrhage 3. bradycardia 4. hyperthermia

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A doctor orders a narcotic analgesic for a laboring client. In which of the following situations is it essential for the nurse to hold the medication and not administer it? 1. Contraction pattern is every 3 min × 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90.

2. Late decelerations are indicative of uteroplacental insufficiency and indicate fetal distress. It is inappropriate to administer a central nervous system (CNS) depressant to the mother at this time.

A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the practitioner. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.

2. Sinusoidal patterns are related to Rh isoimmunization, fetal anemia, severe fetal hypoxia, or a chronic fetal bleed. They also may occur transiently as a result of Demerol (meperidine) or Stadol (butorphanol) administration. As this client has just been admitted, medication administration is not a likely cause. The health care practitioner should be notified.

A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.

2. Standard precautions are indicated in this situation.

Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an anaphylactoid syndrome of pregnancy during labor? 1. Client will be infection free at discharge. 2. Client will exhibit normal breathing function at discharge. 3. Client will exhibit normal gastrointestinal function at discharge. 4. Client will void without pain at discharge.

2. The appropriate nursing care outcome is that the client survives and is breathing normally at discharge.

The physician has ordered dinoprostone for four clients at term. The nurse should question the order for which of the women? 1. Primigravida with Bishop score of 4. 2. Multigravida with late decelerations. 3. Primigravida with fetal heart rate of 155 and Bishop score of 4 4. G6 P3202 with blood pressure 140/90 and pulse 92.

2. This client's fetus is already showing signs of fetal distress. Induction increases the risk of fetal injury.

The nurse understands that a client undergoing an emergency cesarean section is likely experiencing a great deal of anxiety. Which of the following nursing interventions would be appropriate for this client? 1. Apply antiembolic boots bilaterally. 2. When possible, explain all procedures slowly and carefully 3. Administer an antacid per MD orders. 4. Monitor the FHR and maternal vital signs.

2. The nurse should explain all procedures slowly and carefully.

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.

2. The nurse should notify the health care practitioner of the client's request.

A client whose fetus is exhibiting signs of erythroblastosis fetalis is admitted to the labor and delivery unit. The nurse would expect to see which of the following fetal heart rate monitor tracings? 1. marked fetal heart rate variability 2. prolonged fetal heart rate accelerations 3. sinusoidal fetal heart rate pattern 4. periodic variable decelerations

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A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartum complications? 1. Prolonged labor. 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta.

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The nurse is assessing the Bishop score on a postdates client. Which of the following measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilation. 4. Fetal station. 5. Cervical position.

3, 4, and 5 are correct. 3. Cervical dilation is part of the Bishop score. 4. Fetal station is part of the Bishop score. 5. Cervical position is part of the Bishop score.

During the delivery of a macrosomic baby, the woman developed a fourth-degree laceration. The nurse has just reviewed with the client, the provider's education about the laceration. Which comment by the client indicates she understands the extent of her laceration? 1. My laceration extended Into the muscles around my anus. 2. My laceration extended into my urinary meatus where I pee 3. My laceration extended through my rectal sphincter into my rectum 4. My laceration extended up to my clitoris

3. A fourth-degree laceration extends through the rectal sphincter.

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? 1. Full dilation of the cervix. 2. Full effacement of the cervix. 3. Station of -3. 4. Frequency every 5 minutes.

3. A high station is consistent with the data in the scenario.

Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk. The nurse should question this order.

There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3 P0020, in active labor. 2. Age 22, G1 P0000, eclampsia. 3. Age 25, G4 P3003, last delivery by cesarean section. 4. Age 32, G2 P0100, first baby died during labor.

3. A woman, no matter what her age, who has had a previous cesarean section is at risk for uterine rupture.

A 30-year-old G2 P0010 in preterm labor is receiving nifedipine. Which of the following maternal assessments noted by the nurse must be reported to the health care practitioner immediately? 1. Heart rate of 100 bpm. 2. Wakefulness. 3. Audible rales. 4. Daily output of 2,000 mL.

3. Audible rales should be reported to the health care practitioner.

The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as: 1. The baby is severely acidotic. 2. The baby must be delivered as soon as possible. 3. The results are equivocal, warranting further sampling. 4. The results are within normal limits.

3. Further testing is indicated.

A woman has been in the second stage of labor for 2 1/2 hours. The fetal head is at +4 station and the fetal heart is showing recurrent late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time? 1. Obtain a consent for the use of forceps. 2. Encourage the woman to push between contractions. 3. Assess the fetal heart rate after each contraction. 4. Advise the woman to refuse the use of forceps.

3. The FH should always be assessed after each contraction during stage 2. Plus, this baby is especially at risk because the stage is prolonged and the physician is using forceps for delivery.

When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped or U-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow.

3. The contractions described in the scenario result from cord compression (variable decelerations).

A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin. Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations.

3. The duration of the contractions is prolonged. The baby will be deprived of oxygen.

A client, 39 weeks' gestation with fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? 1. Palpate the woman's bladder to check for urinary retention. 2. Obtain a urine culture to check for a urinary tract infection. 3. Assess the fluid with nitrazine and see if the paper turns blue. 4. Percuss the woman's uterus and monitor for ballottement.

3. The fluid should be assessed with nitrazine paper.

A client, G3 P2002, 40 weeks' gestation, has just been admitted in early labor. she has vaginal candidiasis. Which of the following should the nurse advise the woman? 1. She may need a cesarean delivery. 2. She will be treated with antibiotics during labor. 3. The baby may develop thrush after delivery. 4. The baby will be isolated for at least one day.

3. Thrush is the term given to oral candidiasis, which the baby may develop after delivery.

A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select all that apply. 1. Change in contraction pattern from q 3 min × 90 sec to q 2 min × 60 sec. 2. Change in fetal heart pattern from no decelerations to early decelerations. 3. Change in beat-to-beat variability from minimal to moderate. 4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.

4 and 5 are correct. 4. When the fetal heart rate pattern is greater than 200 bpm, the medication should be stopped. 5. Terbutaline is contraindicated when the membranes have ruptured prematurely.

A client is in active labor. Which of the following assessments would warrant immediate intervention? 1. Maternal PaCO2 of 40 mm Hg. 2. Alpha-fetoprotein values of 2 times normal. 3. 3 fetal heart accelerations during contractions. 4. Recurrent late decelerations with minimal variability

4. A fetal scalp pH of 7.19 is indicative of an acidotic fetus.

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? 1. Color of the amniotic fluid. 2. Maternal blood pressure. 3. Cervical effacement. 4. Uterine resting tone.

4. The uterine resting tone should be carefully monitored with an internal pressure electrode during amnioinfusion. because fluid is being instilled into the uterine cavity, there is potential for the fluid to overload the space. As a result, the uterine resting tone will increase dramatically with the potential that the uterus could rupture. It is critically important, therefore, that the nurse monitor the resting tone fre- quently throughout the procedure

A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurrent late decelerations. The client's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.

4. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated.

The nurse notes that the fetus of a laboring client is exhibiting signs of fetal intolerance of labor. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler's position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.

4. Increasing the IV rate helps to improve perfusion to the placenta.

A woman, G3 P2002, 42 weeks' gestation, is admitted to the labor suite for induction. A biophysical profile (BPP) report on the client's chart states BPP score of 6 of 10. The nurse should monitor this client carefully for which of the following? 1. Maternal hypertension. 2. Maternal hyperglycemia. 3. Increased fetal heart variability. 4. Late fetal heart decelerations.

4. The baby is at high risk for late fetal heart decelerations secondary to a postmature placenta.

A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual odor." 3. "Your labor should start very soon." 4. "Have you felt the baby move since the membranes broke?"

4. The most important information needed by the nurse should relate to the health and well-being of the fetus. Fetal movement indicates that the baby is alive.

A client with an obstetrical history of G1 P0000 received dinoprostone for cervical ripening 8 hours ago. The Bishop score at that time was 4. The Bishop score is now 10. Which of the following actions by the nurse is appropriate? 1. Perform nitrazine analysis of amniotic fluid. 2. Report abnormal findings to the obstetrician. 3. Place woman on her side. 4. Monitor for onset of labor.

4. The nurse should monitor this client for the onset of labor.

The primary healthcare provider for a client at 38 1/7 weeks' gestation calls the labor and delivery suite to schedule an induction for the next day. The client is having no medical or pregnancy complications. Which of the following responses by the nurse would be appropriate? 1. at what time would you like to begin the induction 2. what is the client's bishop score 3. im sorry but the client will not be able to be induced tomorrow 4. I will have the prostaglandin induction medication prepared

3 before 39주에는 elective inductions 안됨

A charge nurse is working with four nurses new to the obstetrical unit. During their shift, the fetal heart rate patterns on all four fully dilated clients shows minimal variability and late decelerations. The primary healthcare providers all request forceps to speed the deliveries. In which of the situations should the nurse be advised to refuse to provide the delivery forceps? Select all that apply. 1. Maternal history of asthma. 2. Right occiput posterior position at +4 station. 3. Transverse fetal lie. 4. Mentum presentation and -1 station. 5. Maternal history of cerebral palsy.

3 and 4 are correct. 3. A baby in transverse lie is physically incapable of delivering vaginally. 4. It is not appropriate to deliver a baby vaginally who is at -1 station. The baby has yet to engage. This baby would likely be delivered by cesarean section for prolonged fetal distress.

Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4. Shoulder dystocia is an obstetric emergency.

The nurse is monitoring the progressof four women who are in labor. The nurse is aware that he or she will likely need a cesarean delivery? Select all that apply. 1. Fetus is in the left sacral posterior position. 2. Placenta is attached to the posterior portion of the uterine wall. 3. Fetus has been diagnosed with meningomyelocele. 4. Client is hepatitis B surface antigen positive. 5. The lecithin/sphingomyelin ratio in the amniotic fluid is 1.5:1.

1 and 3 are correct. 1. The baby in the LSP position is in a breech presentation. Most breech babies are delivered by cesarean section. 3. The meningomyelocele sac could easily rupture during a vaginal delivery. When a fetus has been diagnosed with the defect, a cesarean is usually performed.

The nurse is triaging four full-term primigravid clients to the labor and delivery unit. The nurse requests a bedside consultation by the health care practitioner for which of the clients? The client who has: Select all that apply. 1. Cervical cerclage. 2. FH 155 with moderate variability. 3. Maternal blood pressure of 92/60. 4. Full effacement. 5. Active herpes simplex 2

1 and 5 are correct. 1. Cervical cerclage, a stitch encircling the cervix, is incompatible with vaginal delivery. 5. Active herpes simplex 2 is an absolute indicator for a cesarean delivery.

A client enters the labor and delivery suite for a labor check. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.

1, 4, and 5 are correct. 1. The client's hepatitis B status should be assessed. 4. The client's group B streptococcus status should be assessed. 5. The client's HIV/AIDS status should be assessed.

A laboring woman, who has developed an apparent anaphylactic syndrome of pregnancy response is not breathing and has no pulse. In addition to calling a code, which of the following actions by the nurse, who is alone with the patient, is appropriate at this time? 1. Perform cardiac compressions and breaths in a 15 to 2 ratio. 2. Provide chest compressions at a depth of at least 2 inches. 3. Compress the chest at the lower 1⁄2 of the sternum. 4. Provide rescue breaths over a 10-second time frame.

2 The protocol for cardiac compression and breath ratio is 30 to Chest compressions should be delivered at a depth of 11⁄2 to 2 inches. The lower half of the sternum should be compressed when delivering car- diac compressions. Each breath should be delivered over a 1-second time frame

Which of the following physical findings would lead the nurse to suspect that a client who has preeclampsia with severe features has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.

2 and 3 are correct. 2. Petechiae may develop when a client is thrombocytopenic, one of the signs of HELLP syndrome. 3. Hyperbilirubinemia develops when red blood cells hemolyze, one of the changes that may develop as a result of liver necrosis. Jaundice is a manifestation of hyperbilirubinemia.

An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 2 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug as ordered 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature.

2. The practitioner should increase the dosage of oxytocin at a minimum time interval of every 30 minutes.

A preterm labor client at 30 weeks' gestation reported rupture of membranes 4 hours ago. This was confirmed on examination. The nurse prepares to administer IM dexamethasone when the client asks why she is receiving the drug, the nurse replies: 1. to help to stop your labor contractions 2. to prevent an infection in your uterus 3. to help to mature your baby's lungs 4. to decrease the pain from the contractions

3

A nurse is caring for a primiparous client at 35 weeks' gestation. The client is having uterine contractions. Which of the following confirms that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds.

3 and 4 are correct. 3. The dilation of 3 cm is indicative of preterm labor. 4. A cervical length of 2 cm is indicative of preterm labor.

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min × 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin 2. Methylergonovine maleate 3. Magnesium sulfate. 4. Morphine sulfate.

3. Magnesium sulfate is a tocolytic agent. It would be appropriate for this medication to be administered at this time.

Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with moderate variability and early decelerations. Immediately following the procedure, an the tracing shows a fetal heart rate of 120 with prolonged decelerations. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta.

3. The drop in fetal heart rate with variable decelerations indicates that the cord has likely prolapsed.

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G2 P0010, 27 weeks' gestation. 2. G3 P1101, 17 years of age. 3. G4 P2101, cancer survivor. 4. G5 P1211, cocaine abuser.

4. Cocaine is a powerful vasoconstrictive agent. It places pregnant clients at high risk for placental abruptions.

A pregnant woman, G3 P2002, had her two previous children by cesarean section. She would like to have a vaginal birth this time and requests a trial of labor after cesarean section (TOLAC). Which of the following situations would mandate that this delivery also be by cesarean? 1. The woman refuses to have a regional anesthesia. 2. The woman is postdates with intact membranes. 3. The baby is in the occiput posterior position. 4. The previous uterine incisions were vertical.

4. The presence of vertical incisions in the uterine wall is an absolute indication for a cesarean delivery.

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? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

2. Flexing the woman's hips sharply toward her abdomen, called McRoberts' maneuver, is appropriate.

The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurrent late decelerations. The nurse notes a moderate amount of greenish-colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following condition is the client at risk for, at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.

2. Green amniotic fluid in the presence of late decelerations is indicative of fetal distress.

The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL. 2. G2 P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1 P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2 P1001, 39 weeks, Rh-negative, today's hematocrit 31%.

3. A placental abruption is a life-threatening situation for the fetus. It has been 15 minutes since the fetal heart was assessed. This is the nurse's priority.

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? 1. Administer betamethasone (Celestone) 12 mg IM daily times 2. 2. Maintain strict bed rest. 3. Assess cervical dilation. 4. Regulate intravenous (Ringer's lactate: drip rate to 150 mL/hr).

3. An order to assess the woman's cervical dilation should be questioned.