exam 3
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
headache following anesthesia
A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?
Before reporting to the RN, determine the uterine contraction pattern.
The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?
Pain originates from the cervix and lower uterine segment.
A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:
"I may end up with a severe headache from the spinal anesthesia."
When assessing the effectiveness of the obstetrical regional analgesia received by a client, the nurse recognizes it is successful by the complete loss of pain sensation at which level of the spinal cord?
below t8 level
During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?
ischial spine
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?
maternal hypotension and fetal bradycardia
A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?
Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask.
A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering?
antiretroviral
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?
assess fetal heart rate for fetal safety
A client has just received combined spinal epidural. Which nursing assessment should be performed first?
assess vitals
Which order by the health care provider would the nurse question if given in the active stage of labor?
secobarbital for relaxation
On examination, the nurse determines the client is at 50% effacement. This means:
the cervical canal is 1 cm long.
The pain of labor is influenced by many factors. What is one of these factors?
the woman is prepared for labor and birth
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?
Acceleration of at least 15 bpm for 15 seconds
When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching?
"You have no trouble walking around and using the bathroom after you receive the epidural."
The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action?
"my lips and fingers are tingling"
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?
clear/straw colored fluid
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:
effleurage
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
fetal status
There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?
it can be given by a nurse
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding?
less anxiety
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine
The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
one fingerbreadth below the umbilicus
A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? Select all that apply.
spinal abnormality hypovolemia coagulation defects
What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?
starting an IV and hanging IV fluids
To assess the frequency of a woman's labor contractions, the nurse would time:
the beginning of one contraction to the beginning of the next
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?
vaginal examination
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg
When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?
fundus two fingerbreadths below umbilicus and firm
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
green colored fluid in the vagina
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?
Have the client pant and blow through the contraction.
A nurse is meeting with a client to develop the nursing care plan for her delivery to include the use of an injectable pain medication. When comparing the various options for the client, which advantage of using an intrathecal anesthesia over an epidural anesthesia should the nurse point out?
Intrathecal anesthesia is a simpler technique providing quicker pain relief than epidural anesthesia.
When developing a labor plan with the client, which outcome is the priority?
The client will direct her pain management techniques.
Patterned breathing techniques used in labor provide which benefits? Select all that apply.
conscious relaxation distraction pain relief without special tools
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant
The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?
provide care under supervision of a RN
The nurse notes that the client has a moderate amount of bleeding after birth. Which instruction is anticipated to control bleeding?
put the newborn at the breast to suck
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?
difficulty breathing
The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?
Encourage her through the contractions, explaining why she cannot receive any pain medication.
A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?
palpate the mother's radial pulse at the same time
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.
uterine resting tone frequency of contractions intensity of contractions
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?
it distracts your brain from the sensations of pain
