Chapter 12

A client is admitted to the birthing unit in active labor. Cervical dilation has progressed from 2 to 3 cm during an 8-hour period. The health care provider determines that she has hypotonic dystocia, and an infusion of oxyticin is prescribed to augment her contractions what is the MOST important nursing action at this time? 1) Checking the perineum for bulging 2) Documenting the fetal heart rate and its variations 3) Preparing the client for an emergency C- section birth 4 Monitoring the duration and intensity of the contractions

1) Checking the perineum for bulging

A client at 38 weeks gestation is admitted for induction of labor. Her membrane ruptured 12 hours ago. There are no other signs of labor. Which medication does the nurse anticipate will be prescribed ? 1)Oxytocin 2) Estrogen 3)Ergonovine 4)Progesterone

1)Oxytocin

What us the safest posotion for a woman in labor when a nurse observes a prolapsed cord? 1) Prone 2) Fowler 3) Lithotomy 4 Trendelenburg

4 Trendelenburg

A client in labor at 39 weeks gestation is told by the health care provider that she will need a cesarean birth. The nurse reviews the client's prenatal history. What preexisting condition is the MOST likely reason for the cesarean birth? 1) Gonorrhea 2) Chlamydia 3) Chronic hepatitis 4) Active genital herpes

4) Active genital herpes

A pregnant client with severe abdominal pain and heavy bleeding is prepared fora cesarean birth. What is the PRIORITY nursing intervention? 1) Teaching coughing and deep- breathing techniques 2)Sterilizing the surgical site and administering an enema 3) Providing a sterile gown and inserting and indwelling catheter. 4) Obtaining an informed consent and assessing for drugs allergies

4) Obtaining an informed consent and assessing for drugs allergies

A client has been receiving Oxytocin to augment labor. For what adverse reaction caused by a prolonged oxytocin infusion should the nurse monitor the client ? A. Change in affect B. Hyperventilation C. Water intoxication D. Elevated temperature

C. Water intoxication

A client is admitted to the birthing unit in active labor. An amniotomy is performed. What physiologic change does the nurse expect to occur after the procedure? A. Diminished vaginal bleeding B. Less discomfort with contraction C. Progressive dilation and effacement D. Increased maternal and fetal heart rates

D. Increased maternal and fetal heart rates

An expectant couple ask the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the position of the fetus is what? A. Breech B. Transverse C. Occiput anterior D. Occiput posterior

D. Occiput posterior

A client is receiving an IV piggyback infusion of oxytocin to augment labor. The nurse identifies that there have been three contractions lasting 80 to 90 seconds that are less than 2 minutes apart. There is a specific protocol that is followed in response to this observation. List in order of priority the nursing actions that should be taken. A. Check the fetal heart rate B. Stop the piggyback infusion C. Notify the health care provider D. Administer oxygen

Stop the piggyback infusion Check the fetal heart rate. Administer oxygen via face mask Document maternal/fetal response Determine whether the contractions have diminished Notify the health care provider

A primigravida is concerned about the health of her baby and asks the nurse, "What is the most common cause of death of babies?" The nurse explains that the cause of more than half of neonatal deaths in the U.S. is due to what? a. Atelectasis b. Preterm births c. Congenital heart disease d. Respiratory distress syndrome

b. Preterm births

A client who is at 26 weeks' gestation tells a nurse at the prenatal clinic that she has pain when urinating, back tenderness, and pink-tinged urine. A diagnosis of pyelonephritis is made. What is the most important nursing intervention at this time? a. Limiting fluid intake b. Examining her urine for protein c. Observing for signs of preterm labor d. Maintaining her on a moderate-sodium diet

c. Observing for signs of preterm labor

During an emergency birth the fetal head is crowning on the perineum. How should a nurse support the head as it is being born? A. Apply suprapubic pressure B. Place a hand firmly against the perineum C. Distribute the fingers evenly around the head D. Maintain pressure against the anterior fontanel

C.

A client asks the nurse at the prenatal clinic whether she can continue to have sexual relations while pregnant. What is an indication that the client should refrain from intercourse during pregnancy? a. Fetal tachychardia b. Presence of leukorrhea c. Premature rupture of membranes d. Being close to expected date of birth

c. Premature rupture of membranes

Despite medication, a client's preterm labor continues, her cervix dilates, and birth appears to be inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival? a. Fenoterol b. Misoprostol c. Terbutaline d. Betamethasone

d. Betamethasone

A client arrives at the clinic in preterm labor, and the terbutaline is prescribed. For what therapeutic effect should the nurse monitor the client? a. Increased blood pressure and pulse b. Reduction of pain in the perineal area c. Gradual cervical dilation as labor progresses d. Decreased frequency and duration of contractions

d. Decreased frequency and duration of contractions