Exam 3 OB
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction? hypotension diaphoresis headache tremors
hypotension
A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an IV infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? carefully titrating the oxytocin based on the client's pattern of labor monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes instructing the client to ambulate as tolerated helping the client use breathing exercises to manage her contractions
instructing the client to ambulate as tolerated
A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. The client's vital signs are: blood pressure, 120/80 mm Hg temperature, 100°F (37.8°C) pulse, 100 bpm respirations, 18 breaths/minute Which medication would the nurse expect the primary health care provider (HCP) to prescribe? intravenous penicillin intravenous gentamicin sulfate intramuscular betamethasone intramu
intravenous penicillin
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? active phase latent phase expulsive phase transitional phase
latent phase
An assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? excitement loss of control numbness of the legs feelings of relief
loss of control
What assessment data of a laboring woman would require further intervention by the nurse? fetal heart rate (FHR) 150 beats/minute maternal heart rate 125 beats/minute temperature of 99.1° F (37.27° C) moderate contractions 3 minutes apart
maternal heart rate 125 beats/minute
What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia? giving frequent sips of water applying extra blankets for warmth providing frequent perineal cleansing offering encouragement and support
offering encouragement and support
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem? urinary retention hyperventilation ineffective coping pain
pain
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding? passage of meconium by the fetus maternal intrauterine infection Rh incompatibility between the birth mother and the fetus maternal sexually transmitted disease
passage of meconium by the fetus
A parent expresses concern that picking up the infant whenever they cry will spoil them. What is the nurse's best response? "Allow them to cry for no longer than 45 minutes, then pick them up." "Babies need comforting and cuddling; meeting these needs will not spoil them." "Babies this young cry when they are hungry; try feeding them when they cry." "If it seems as if nothing is wrong, don't pick them up; the crying will stop eventually."
"Babies need comforting and cuddling; meeting these needs will not spoil them."
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client makes which statement? "Nalbuphine and promethazine will give relief from pain and nausea during early labor." "I can have an epidural as soon as I start contracting." "If I have a cesarean, I can have an epidural." "If I have an emergency cesarean, I may be put to sleep for the birth."
"I can have an epidural as soon as I start contracting."
After the nurse explains the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed? "I'm going to have a higher blood pressure." "My membranes are likely to have a foul odor." "My contractions are going to be less painful." "I should try to push with each contraction."
"I should try to push with each contraction."
A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the physician to order: betamethasone. dinoprostone. ergonovine. terbutaline.
terbutaline.
A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching? "It is permissible to douche if the fluid irritates my vaginal area." "I can take either a tub bath or a shower when I feel like it." "I should limit my fluid intake to less than 1 quart (0.95 L) daily." "I should contact the health care provider if my
"I should contact the health care provider if my temperature is 100.4°F (38°C) or higher."
A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the teaching when the client makes which statement? "My baby's heart rate is slow because of my infection." "My infection is the cause of my hypertonic labor pattern." "Women who are overweight are more likely to get this infection." "If left untreated, my baby might be born with an infection."
"If left untreated, my baby might be born with an infection."
A pregnant client's partner coaches them with breathing and relaxation techniques as they were taught in birth preparation classes. When the client reaches 8-cm dilation (dilatation), she screams out, "I can't do this anymore!" Which suggestion would be most helpful for the client's partner? "Let me take over the coaching for a while." "Ask your partner if they want anesthesia." "Tell your partner that it will be over soon." "Maintain direct eye contact and breathe with your pa
"Maintain direct eye contact and breathe with your partner."
A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood? "The medication will be administered while I am in the prone position." "The anesthetic may cause a severe headache, which is treatable." "My blood pressure may increase if I lie down too soon after the injection." "I can expect immediate anesthesia that can be reversed very easily."
"The anesthetic may cause a severe headache, which is treatable."
A multigravida with a history of cesarean birth due to fetal distress is admitted for a trial labor after a cesarean and possible vaginal birth. After several hours of active labor, the health care provider prescribes nalbuphine. The nurse evaluates the drug as effective when the client makes which statement? "I'll be able to get some sleep until after the birth." "The contractions don't seem as painful as before." "The contractions don't seem as painful as before." "I don'
"The contractions don't seem as painful as before."
During preparation for a parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions? "Walking around helps to decrease true contractions." "True labor contractions are irregular and intense." "The duration and frequency of true labor contractions remain the same." "True labor contractions are felt first in the lower back, then the abdomen."
"True labor contractions are felt first in the lower back, then the abdomen."
Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? "Do you have any chronic illnesses?" "Do you have any allergies?" "What is your expected due date?" "Who will be with you during labor?"
"What is your expected due date?"
Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider? A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps. Using forceps will cause the neonate to develop a cephalhematoma and a vacuum extractor will not. Assisted vaginal births are very commonplace, especially in clients who have received epidurals. Clients having assisted vaginal
A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps.
The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. What should the nurse do next? Inform the client about the cause of the fetal heart rate pattern. Prepare the client for an immediate cesarean birth. Evaluate the contraction pattern for 15 minutes. Administer oxygen at 8 to 10 L by mask.
Administer oxygen at 8 to 10 L by mask.
A multigravid client in active labor at term suddenly sits up and says, "I can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color. After calling for assistance, the nurse should take which action next? Administer oxygen by face mask. Begin cardiopulmonary resuscitation. Administer intravenous oxytocin. Obtain an prescription for intravenous fibrinogen.
Administer oxygen by face mask.
A 31-year-old client, G3, T0, P2, A0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission, and the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client? Assess maternal contraction and fetal heart rate pattern. Reassure the client that this baby will be
Assess maternal contraction and fetal heart rate pattern.
A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse they feel the need to have a bowel movement. What should the nurse do first? Have naloxone available in the birthing room. Complete a vaginal examination. Prepare for birth. Document the client's relief due to pain medication.
Complete a vaginal examination.
A client with active genital herpes is admitted to the labor and birth unit. During the first stage of labor. Which type of birth should the nurse anticipate for this client? Mid forceps Low forceps Induction Cesarean
Cesarean
External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern of the fetal heart rate. What action should the nurse take first? Notify the anesthesiologist. Change the client's position. Administer oxygen at 2 L by mask. Prepare the client for a cesarean birth.
Change the client's position.
For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes? Position the client on the left side. Prepare the client for a cesarean birth. Assess the client's blood pressure. Check the fetal heart rate.
Check the fetal heart rate.
A 34-year-old multigravida at 36 weeks' gestation is diagnosed with preterm labor. The client has experienced one infant death due to preterm birth at 28 weeks' gestation. On admission to the antenatal unit, the nurse determines that the fetal heart rate is 140 bpm. What action should the nurse take next? Administer oxygen by mask at 8 L/min. Notify the client's health care provider immediately. Continue monitoring the client and fetus. Recheck the fetal heart rate again in 5 minutes.
Continue monitoring the client and fetus.
The nurse is caring for a multigravid client in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. What should the nurse do? Turn the client to their left side. Ask the client to push in the squatting position. Continue to monitor the client and fetus. Administer oxygen by mask at 8 L.
Continue to monitor the client and fetus.
A client is admitted to the labor area for induction with intravenous oxytocin because they are 42 weeks' pregnant. What should the nurse include in the induction teaching plan for this client? Continuous fetal heart rate monitoring will be implemented. Frequent ultrasound examinations will be performed. At least 5 to 10 fetal scalp pH tests will be performed. Oligohydramnios will be carefully evaluated.
Continuous fetal heart rate monitoring will be implemented.
The health care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding? The client is sedated. There is increased placental perfusion. There is improvement in fetal lung function. Contractions cease.
Contractions cease.
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? Contractions will be stronger and more uncomfortable and will peak more abruptly. Contractions will be weaker, longer, and more effective. Contractions
Contractions will be stronger and more uncomfortable and will peak more abruptly.
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug? The cervix will begin to dilate 2 cm per hour Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, with moderate-intensity resting tone between contractio
Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, with moderate-intensity resting tone between contractions.
A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take? Turn the client to her left side. Administer oxygen via facemask at 10 to 12 L/minute. Notify the health care provider (HCP) of the situation. Document fetal well-being.
Document fetal well-being.
A nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan? Anxiety related to the facility environment Fear related to a potentially difficult childbirth Compromised family coping related to hospitalization Acute pain related to
Fear related to a potentially difficult childbirth
After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when they say they will need to do which action? Be in a semi-Fowler position or a position of comfort. Flex the thighs onto the abdomen before bearing down. Exert downward pressure as if having a bowel movement. Hold their breath throughout the length of the contraction.
Hold their breath throughout the length of the contraction.
A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately? Pad the side rails. Place a pillow under the left buttock. Insert a padded tongue blade into the mouth. Maintain a patent airway.
Maintain a patent airway.
While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, the amniotic membranes rupture spontaneously. The client's cervix is 5-cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is normal. What should the nurse do first? Perform a vaginal examination to determine dilation (dilatation). Auscultate the client's blood pressure. Note the color, amount, and odor of the amniotic fluid. Prepare the client for imminent birt
Note the color, amount, and odor of the amniotic fluid.
A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first? Place gentle pressure upward on the fetal head. Place the cord back into the vagina to keep it moist. Begin oxygen by face mask at 8 to 10 L per minute. Turn the client on the left side.
Place gentle pressure upward on the fetal head.
Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? Place the client in the Trendelenburg position. Administer oxytocin intravenously. Ask the client to begin pushing. Cover the cord with sterile towels.
Place the client in the Trendelenburg position.
The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priorityintervention? Administer IV oxytocin as ordered. Apply an internal fetal scalp eletrode. Instruct the client to push. Prepare for an emergency cesarean birth.
Prepare for an emergency cesarean birth.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor? Breathe slowly after each contraction. Avoid the use of analgesics for labor pain. Remain in a side-lying position with the head elevated. Request local anesthesia for vaginal birth.
Remain in a side-lying position with the head elevated.
A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? Report a heart rate greater than 120 beats/minute to the health care provider. Take terbutaline every 4 hours, during waking hours only. Call the health care provider if the fetus moves 10 times in an hour. Increase activity daily if not fatigued.
Report a heart rate greater than 120 beats/minute to the health care provider.
A nurse needs to obtain a good monitor tracing on a client in labor. The client lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which action should the nurse perform first? Reposition the client to her left side. Immediately take the client's blood pressure and summon the health care provider (HCP). Start oxygen at 6 L via nasal cannula. Increase the IV fluids to correct the client's dehydration.
Reposition the client to her left side.
A nurse notices repetitive late decelerations on the fetal heart monitor. What are the best initial actions by the nurse? Prepare for birth, reposition the client, and tell the client to begin pushing. Perform a sterile vaginal examination, increase intravenous (IV) fluids, and apply oxygen. Notify the provider, explain the findings to the client, and tell the client to begin pushing. Reposition the client, apply oxygen, and increase IV fluids.
Reposition the client, apply oxygen, and increase IV fluids.
A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next? Continue monitoring per standards of care. Stop the magnesium sulfate infusion. Increase the infusion rate by 5 gtt/minute. Decrease the infusion rate b
Stop the magnesium sulfate infusion.
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed oxytocin intravenously after delivery of the placenta. Which sign would indicate to the nurse that the placenta is about to be delivered? The cord lengthens outside the vagina. There is decreased vaginal bleeding. The uterus cannot be palpated. The uterus changes to a discoid shape.
The cord lengthens outside the vagina.
Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients? The nurse should assign priority to the first client. Her leaking amniotic fluid indicates that she'll soon go into labor. The nurse should assign priority to the second clie
The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? The time of membrane rupture The frequency of contractions The presence of fetal movement after the membranes ruptured The color of the ruptured fluid
The time of membrane rupture
Following an epidural and placement of internal monitors, a client's labor is augmented with oxytocin. Contractions are lasting longer than 90 seconds and occur every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an abnormal fetal heart rate and pattern. Which action should the nurse take first? Notify the health care provider (HCP). Turn off the oxytocin infusion. Turn the client to their left side. Increase the maintenance intravenous (IV) fluids.
Turn off the oxytocin infusion.
A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage their pain? Select all that apply. Walk in the hospital room. Use slow chest breathing. Request pain medication on a regular basis. Lightly massage the abdomen. Sip ice water.
a, b, d
A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply. a. interpretation of the fetal monitor strip b. analgesia or anesthesia being used c. previous methods of birth control d. support persons with the client e. prior birth history
a, b, d, and e
Which statement describes the term fetal position? a. relationship of the fetus's presenting part to the mother's pelvis b. fetal posture c. fetal head or breech at cervical os d. relationship of the fetal long axis to the mother's long axis
a.
A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6-cm dilated. After administration of this anesthesia, which assessment would be most important? fetal heart rate maternal pulse level of anesthesia level of consciousness
fetal heart rate
Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? an increased sense of rectal pressure a decrease in intensity of contractions an increase in fetal heart rate variability episodes of nausea and vomiting
an increased sense of rectal pressure
The nurse is managing the care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client? oxygen saturation monitoring every half hour supine positioning on the back, if it is comfortable anesthesia and pain level assessment every 30 minutes vaginal bleeding, rupture of membrane assessment every shift
anesthesia and pain level assessment every 30 minutes
In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion? persistent fetal bradycardia variable decelerations fetal heart rate accelerations late decelerations
fetal heart rate accelerations
What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? acme of one contraction to the beginning of the next contraction beginning of one contraction to the end of the next contraction end of one contraction to the end of the next contraction beginning of one contraction to the beginning of the next contraction
beginning of one contraction to the beginning of the next contraction
When assessing the fetal heart rate tracing, a nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve: fetal hypoxia. the contraction pattern. the status of a trapped cord. maternal comfort.
fetal hypoxia.
A nurse recognizes that labor is divided into how many stages? two three four five
four
A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the bestindication that the client is in true labor? fetal descent into the pelvic inlet cervical dilation and effacement painful contractions every 3 to 5 minutes leaking amniotic fluid clear in color
cervical dilation and effacement
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean birth? client at 40 weeks' gestation whose fetus weighs 8 lb (3630 g) by ultrasound estimate client at 37 weeks' gestation with the fetus in the right occiput posterior (ROP) position client at 32 weeks' gestation with the fetus in the breech position client at 38 weeks' gestation with active herpes lesions
client at 38 weeks' gestation with active herpes lesions
A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred? abruptio placentae prolapsed cord partial placenta previa complete uterine rupture
complete uterine rupture
The end of the third stage of labor is marked by what event? the birth of the neonate complete dilation delivery of the placenta transfer of the client to the postpartum bed
delivery of the placenta
A full-term client is admitted for induction of labor. When admitted, the client's cervix is effaced 25% but has not dilated. The initial goal is cervical ripening before labor induction. Which drug will prepare the cervix for induction? nalbuphine oxytocin dinoprostone betamethasone
dinoprostone
While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? duration, frequency, and intensity dilation, duration, and frequency frequency, duration, maternal position dilation, effacement, position
duration, frequency, and intensity
A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding? prolonged decelerations early decelerations late decelerations accelerations
early decelerations
An infant diagnosed with Hirschsprung disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate? assessing the adequacy of their coping skills reassuring them that their child will be fine encouraging them to ask questions giving them printed material on the procedure
encouraging them to ask questions
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if any of the clients have which finding? an episode of nausea after administration of an epidural anesthetic contractions 3 minutes apart and lasting 40 seconds evidence of spontaneous rupture of the membranes sleeping after administration of intravenous (IV) nalbuphine
evidence of spontaneous rupture of the membranes
x A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypox
excessive fetal activity and fetal tachycardia
A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6-cm dilated. After administration of this anesthesia, which assessment would be most important? fetal heart rate maternal pulse level of anesthesia level of consciousness
fetal HR
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position? breech transverse posterior anterior
posterior
A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time? placing the client in bed to begin fetal monitoring preparing for immediate delivery checking for ruptured membranes providing comfort measures
preparing for immediate delivery
The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to prevent seizures. reduce blood pressure. slow the process of labor. increase diuresis.
prevent seizures.
The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition? increased intensity of contractions fetal head engagement prolapsed cord a need for an analgesic medication
prolapsed cord
A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to: slow contractions. enhance fetal growth. prevent infection. promote fetal lung maturity.
promote fetal lung maturity.
A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor? encouraging ambulation serving a nutritious diet promoting adequate hydration performing nipple stimulation
promoting adequate hydration
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. The client's cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next? red blood cell count degree of discomfort urinary output temperature
temperature
When assessing the fetal heart rate tracing, a nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if the fetal heart rate remains at greater than 160 beats/minute for 5 minutes. the fetal heart rate remains at greater than 160 beats/minute for 10 minutes. the fetal heart rate remains at greater than 160 beats/minute for more than 20 minutes. the fetal heart rate is at least 170 beats/minute at any time.
the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.
Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation (dilatation) at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client feels a strong need to have a bowel movement. What is the client most likely experiencing? a precipitous labor pattern fear and anxiety related to the labor outcome spontaneous rupture of the membranes the second stage
the second stage of labor
A primigravid client at 32 weeks' gestation with ruptured membranes is prescribed to receive betamethasone 12 mg intramuscularly for two doses 24 hours apart. When teaching the client about the medication, what should the nurse include as the purpose of this drug? to prevent potential infection to accelerate fetal lung maturity to reduce contraction frequency to improve the fetal heart rate pattern
to accelerate fetal lung maturity
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor? active phase latent phase descent phase transitional phase
transitional phase
The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? head chest umbilical cord placenta
umbilical cord
Which fetal presentation is most favorable for birth? vertex presentation transverse lie frank breech presentation posterior position of the fetal head
vertex presentation
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Membranes are intact and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time? resting in the right lateral recumbent position lying in the left lateral recumbent position walking around in the hallway sitting in a comfortable chair for a period of time
walking around in the hallway