exit h (1)
A pregnant client is being prepared for a pelvic examination. She reports that she is always tired and feels sick to her stomach, especially in the morning. What is the best response by the nurse?
Let's discuss ways to resolve these common problems.
A nurse concludes that a client's placenta has separated during the third stage of labor. What assessment supports the nurse's conclusion?
A gush of blood
A laboring client experiences a spontaneous rupture of membranes. The nurse's priority is:
Assessing the fetal heart rate
During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?
Breathe into her cupped hands.
A nurse is caring for a primigravida during labor. At 7 cm of dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?
Butorphanol (Stadol)
A nurse helps a client to the bathroom to void several times during the first stage of labor. This is done because a full bladder:
May inhibit the progress of labor
An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned:
Occiput posterior
What nursing action is the priority for a client in the second stage of labor?
Promote effective pushing by the client.
Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. The nurse should immediately:
Reposition the client from supine to left lateral.
Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration.
Repositioning the client from side to side
Which position does the nurse teach the client to avoid when she experiences back pain during labor?
Supine position
A couple who recently emigrated from Israel tells a nurse in the prenatal clinic that they are concerned about a genetic disease that is prevalent among Jewish people. Which genetic screening should the nurse expect the health care provider to recommend to determine the possibility of the couple's child's inheriting the disease?
Tay-Sachs disease
A client in active labor arrives in the birthing unit, and birth is imminent. What is the most important question for the nurse to ask at this time?
When is your baby's expected date of birth?
A nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify?
first
An almost term client reports that her fetus is moving less this week than last week. Which responses are appropriate? Select all that apply.
"It would be good for you to come to labor and delivery to be evaluated today." Always call the health care provider if you're worried that your baby isn't moving enough." "Let me teach you how to conduct a kick count, and then you can call me when you've done one."
A client in labor is admitted to the birthing room. The nurse's assessment reveals that the fetus is at −1 station. Where is the presenting part?
1 cm above the ischial spines
A laboring client who is positive for Group B Streptococcus is given an initial dose of ampicillin (Omipen) 2 g at 9 am. According to established guidelines for intrapartum management of this client, the next dose should be:
1 g given at 1 pm
A nurse at the prenatal clinic examines a client and determines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation would the nurse expect this assessment finding to occur?
12th week of pregnancy
A client arrives at the prenatal clinic and tells the nurse that she thinks that she is pregnant. The first day of the client's last menstrual period (LMP) was September 14, 2011. Using Nägele's rule, what day of June 2012 is the client's estimated date of birth (EDB)? Record your answer using a whole number for the day of the month.
21
A Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of:
7.5
Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body.
9
Physical assessment of a client in active labor reveals that the cervix is dilated 3 to 4 cm and 50% effaced, the fetus is in the right sacrum anterior (RSA) position, and contractions are 5 minutes apart. Where should the nurse place the stethoscope to best locate the fetal heart tones?
A
A client at 8 weeks' gestation tells the nurse that she has not felt like making love with her husband since becoming pregnant and that she is concerned that her husband does not understand. What is the most appropriate response by the nurse?
A decrease in libido is common during the first trimester of pregnancy."
A 29-year-old gravida 3 para 3, was admitted to the recovery unit 2 hours after the birth of a 9-lb baby girl. The nurse assesses the client an hour later and finds her fundus, which is slightly boggy, three finger breadths above the umbilicus and displaced to the right. The peri pad, which was changed before the client's transfer, is now saturated. The nurse recognizes:
A distended bladder
A nurse is checking the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression?
Abrupt decreases in fetal heart rate that are unrelated to the contractions
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. What information about true labor contractions should the nurse include in a response to the client's question?
Accompanied by progressive cervical dilation
During a prenatal examination a nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for:
Acute hemolytic anemia
A client who is lying in the supine position while in active labor is receiving an intravenous oxytocin (Pitocin) infusion and has external monitors in place. Using the monitoring strips below, identify the appropriate nursing interventions. Select all that apply.
Administer oxygen. Turn the client on the side. Discontinue the oxytocin infusion.
The nurse is preparing a client in active labor for epidural anesthesia. Which prescribed intervention should the nurse initiate before the anesthesiologist administers the epidural?
Administering a 500-mL bolus of lactated Ringer's solution intravenously
A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect, including which of the following? Select all that apply.
Amenorrhea Breast changes Urinary frequency
A client who expected to use the Lamaze technique throughout labor has an emergency cesarean birth. Three days later the client is found crying and tells the nurse that she is extremely disappointed because a cesarean birth was necessary. She asks the nurse why this happened to her. On what factor should the nurse base a response?
An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience.
After a client gives birth, what physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?
Appearance of a sudden gush of blood
A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do?
Apply cold packs and a snugly fitting bra.OJO
What should a nurse teach a non-nursing mother to help relieve the discomfort of engorgement?
Apply cold packs to the breasts frequently.
A nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her about minimizing breast discomfort?
Apply covered ice packs to the breasts.
A client required an extensive episiotomy because her newborn was large. What is a priority nursing intervention that minimizes edema and lessens discomfort at the episiotomy site?
Applying ice packs to the perineum
A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. What nursing action will help relieve this discomfort?
Applying pressure against her sacrum
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats/min, and respirations are 16 breaths/min. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action?
Asking the client when she last changed the perineal pad
A pregnant client is visiting her health care provider for a routine prenatal visit. The nurse measures the client's fundal height at 37 cm. At her last routine visit the fundal height was 32 cm, which correlated directly with her gestation. What is the nurse's next action?
Asking the client whether she has emptied her bladder recently
A nurse is evaluating the effectiveness of fundal massage in a postpartum client 3 hours after giving birth. An intravenous infusion of 10 units of oxytocin (Pitocin) is infusing at a rate of 100 mL/hr. The client's blood pressure is 135/90 mm Hg, the uterus is boggy and 3 cm above the umbilicus and displaced to the right, and the perineal pad is saturated with lochia rubra. What should the nurse do next?
Assist the client to the bathroom
What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?
Assist the client's coach in helping her with the use of breathing techniques.
A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient?
Audible fetal heartbeat
A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?
Auscultating the fetal heart
A client's membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?
Auscultating the fetal heart rate
The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. Contractions should be timed from the:
Beginning of one contraction to the beginning of the next contraction
What finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0° F (36.6° C) and 97.4° F (36.3° C) would be considered critical?
Blood glucose level of 36 mg/dL
A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first time. After the physical examination she tells the nurse, "I can't believe how big I am. Will I get much bigger?" What information about adolescent growth and development does the nurse need to know before responding?
Body image is very important to adolescents, so pregnant teenagers are concerned about body size.
A primigravida in her 10th week of gestation is concerned because she has read that nutrition during pregnancy is important for the growth and development of the fetus. She wants to know something about the foods she should eat. How should should eat. How should the nurse respond initially?
By asking her what she has eaten over the last 3 days
A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond?
C
How does the nurse know that a client at 40 weeks' gestation is experiencing true labor?
Cervical dilation
A client's membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?
Changing the client's position
A woman in labor with her third child is dilated 7 cm, and the fetal head is at station +1. The client's membranes rupture. What should the nurse do first?
Check the fetal heart rate while observing the color of the amniotic fluid.
A pregnant woman at 39 weeks' gestation arrives in the triage area of the birthing unit, stating that she thinks her "water broke." What should the nurse do first?
Check the vaginal introitus for the presence of the umbilical cord.
A client is bleeding excessively after the birth of a neonate. The health care provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin (Pitocin) at a rate of 100 mL/hr. A nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action?
Checking for a distended bladder
A man calls the prenatal clinic to ask the nurse when he should bring his wife to the hospital. He says, "The baby is due in 2 weeks, but she thinks it could be earlier. This is our first baby, and we're nervous." The nurse knows that as a nullipara, it would be important for the client to be seen if the contractions:
Come every 5 minutes for an hour
A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:
Compression by the enlarging uterus
External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action?
Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends
A nurse is caring for a client during an ultrasonogram. What parameters does the nurse expect to be used in the determination of pregnancy dates?
Crown-to-rump measurement until 11 weeks
A client is admitted to the birthing room in active labor. The nurse determines that the fetus is in the left occiput posterior (LOP) position. At what point can the fetal heart be heard?
D
While palpating the fundus of a postpartum client a nurse identifies separation of the abdominal muscles. How should the nurse document this finding?
Diastasic rects
Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?
Different cultural groups favor different essential nutrients.
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take?
Discontinuing the test because the pattern is within the expected range
A pregnant woman arrives in the emergency department, crying, "My baby is coming!" The nurse determines that the fetus's head is crowning and birth is imminent. What should the nurse do to support the baby's head?
Distribute fingers evenly around the head
A client in the 18th week of pregnancy is scheduled for ultrasonography. What instruction should the nurse give the client?
Don't urinate for at least 3 hours before the test."
A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention should the nurse implement?
Donning sterile gloves and applying direct pressure, using sterile gauze
A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with:
Doppler ultrasound at 10 to 12 weeks
A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond?
During the eighth week of the pregnancy
A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief
Eat dry crackers before you get out of bed.
What should a nurse suggest to a pregnant client that might help overcome first-trimester morning sickness?
Eat protein before bedtime."
What recommendation should a nurse give to a client with fluid retention during pregnancy?
Elevate the lower extremities.
`A nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment?
Empty her bladder.
A nurse is preparing a pregnant client for an amniocentesis. What should nursing care include?
Encouraging her to void before the test
While caring for a client during labor, the nurse remembers that the second stage of labor:
Ends at the time of birth
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats/min, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum?
Enlarging area of caput with each contraction
The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is used to:
Estimate fetal age
A client in active labor has an external fetal monitor in place. Using the monitor strip, identify the correct assessment
FHR baseline at150 beats/min
Why should a nurse teach pregnant women the importance of conserving the "spurt of energy" before labor?
Fatigue may influence the need for pain medication.
A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given?
Fetal lung maturity is accelerated.
What is the primary outcome for client care in the third stage of labor?
Firmly contracted uterine fundus
A primigravida client gave birth in a vaginal delivery 24 hours ago. Which findings would be considered normal?
Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present
A client in her second trimester is at the prenatal clinic for a routine visit. While listening to the fetal heart, the nurse hears a heartbeat at the rate of 136 in the right upper quadrant and also at the midline below the umbilicus. What are the sources of these two sounds?
Funic souffle and fetal heart rate
Using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks.
G4, T1, P1, A1, L3
A pregnant client arrives at the prenatal clinic, and the nurse obtains her obstetrical history. The client has two children at home, one born at 38 weeks' gestation and the second born at 34 weeks' gestation. She has also had one miscarriage, at 18 weeks, and an elective abortion. Using the GTPAL system, what is the client's obstetrical record?
G5 T1 P1 A2 L2
When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. How should the nurse respond?
Having her pant-blow during contractions
Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward:
Helping the client maintain control
How can the nurse best manage a client's care during the transition phase of labor?
Helping the client maintain control
A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse identify as the reason for these hemoglobin and hematocrit levels?
Hemodilution
The nurse reviews the blood test results of a client at 24 weeks' gestation. Which finding should be reported to the health care provider?
Hemoglobin: 10.8 g/dL...OJO
A client who is at 12 weeks' gestation tells a nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. What factor is frequently associated with this disorder?
High level of chorionic gonadotropin
A primigravida at 36 weeks' gestation is admitted to the birthing room with ruptured membranes and a cervix that is dilated 2 cm and 75% effaced. What is the priority question the nurse should ask?
How frequent are your contractions?
The nurse is caring for a client who has just received epidural anesthesia. Which finding would be of most concern?
Hypotension
A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored?
Hypotensive episodes
A client who has had a cesarean birth is being discharged. What statement indicates to the nurse that teaching is required?
I don't need perineal care because I didn't give birth through the vagina.
The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious and asks a nurse, "Would it be best for me to leave, seeing as how I don't seem to be doing my wife much good?" What is the best response by the nurse?
I know that this is hard for you. Let me try to help you coach her during this difficult phase.
The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter?
I'm not exactly sure how an epidural works.
A client is scheduled for a nonstress test in the 37th week of gestation. A nurse explains the procedure. Which statement demonstrates that the client understands the teaching?
If the heart reacts well, my baby should do OK when I give birth."
During a routine second-trimester visit to the prenatal clinic a client expresses concern about gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response?
If you add 340 calories a day to your regular diet, you won't become overweight."
A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram?
Increase fluid intake for 1 hour before the procedure.
A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin (Pitocin) infusion is prescribed. What is the priority nursing intervention at this time?
Infusing oxytocin by piggybacking into the primary line The priority nursing intervention when the membranes rupture spontaneously is an assessment of: Variable decelerations or fetal bradycardia
While having contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse do?
Inspect the client's perineum for bulging.
The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?
Instruct her to void immediately before the test.
What is a common problem that affects the client in labor when an external fetal monitor has been applied to her abdomen?
Intrusion on movement
A nurse notes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period?
It may indicate retention of urine with overflow.
While waiting for his 39-year-old wife to change clothes after an amniocentesis, the husband says to the nurse, "I sure hope that they don't find anything wrong because of my wife's age. I don't know how we'd deal with a child with Down syndrome. We already have two small children at home." What is the nurse's best response?
It must be difficult, worrying about whether your baby will be disabled.
A laboring client expresses concern about the effect that an intravenous analgesic may have on her fetus. The best response by the nurse to reassure the client is:
It will be administered during a contraction, when the uterine blood vessels are constricted."
The nurse-midwife palpates the uterus of a client who is at 12 weeks' gestation and determines that it is enlarged and:
Just above the symphysis pubis
The fetus of a client in labor is found to be at +1 station. Where did the nurse locate the fetus's head?
Just below the ischial spines
A client at 30 weeks' gestation visits the clinic for a routine examination. At her last visit she told the nurse that she wanted to diet to avoid losing her figure after the baby's birth and as a result the nurse provided nutrition counseling. At this visit the client weighs 10 lb less than on her previous visit. The nurse suspects that the client is not complying with the pregnancy diet. For what complication should the client be monitored?
Ketonemia
A nurse performs Leopold's maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is:
LOA
A pregnant client at 37 weeks' gestation is taught about signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report:
Leakage of fluid from the vagina
Two days after having a cesarean birth, a client tells a nurse that she has pain in her right leg, and after an assessment the nurse suspects that the client has a thrombus. What is the nurse's initial response?
Maintain bedrest
A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond?
Maintain bedrest.
A 23-year-old primigravida is at her first prenatal appointment today. Ultrasound indicates that she is at 9 weeks' gestation. She asks when she can first expect to feel her baby move. The best response by the nurse is:
Many women are able to first feel light movement between 18 and 20 weeks."
A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm. What should the nurse say while trying to calm the client?
Medication may interfere with the baby's first breaths; keep breathing."
A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?
Meperidine (Demerol)
A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks on the phone to her friends and does not respond when her new baby cries. What is the best immediate intervention?
Modeling appropriate behaviors that encourage infant bonding
The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping because of afterbirth pains?
Multipara who has vaginally delivered three children
A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply.
My ears are ringing." It gets better when I lie down." Bright lights really bother my eyes." My head hurts more when I'm sitting watching TV."
A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. What additional information about the fetus will examination of the amniotic fluid reveal at this time?
Neural tube defect
A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action?
Notifying the health care provider
A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement?
Nurse at least every 3 hours for at least 10 minutes on each breast."
A nurse is assessing the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located?
One or two fingerbreadths below the umbilicus
Four hours after a vaginal birth, a client still has not voided. What is the next nursing action?
Palpating the client's suprapubic area for distention
A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. What should the nurse instruct the client to do?
Pant and then exhale through the mouth with pursed lips
A nurse is caring for a client in the transition phase of labor. What breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation?
Panting-blowing pattern
A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response in language the client will understand?
Peripheral vasomotor activity is promoted.
What information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy?
Physical and emotional changes resulting from pregnancy
A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm3. What is the next nursing action?
Placing the report in the client's record because this is an expected postpartum finding
What does a nurse explain to a pregnant client about the cause of her physiologic anemia?
Plasma volume increases.
A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented?
Precipitous vaginal delivery
On her first visit to the prenatal clinic, a client tells the nurse she is ambivalent about continuing the pregnancy. Why does the nurse conclude that the client is experiencing a crisis?
Pregnancy is a period of change and adjustment to change.
A client is admitted to the birthing unit in active labor. Amniotomy is performed by the health care provider. What physiologic change does the nurse expect to occur after the procedure?
Progressive dilation and effacement
. A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at −1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse do next?
Provide the client with comfort measures used for women in labor.
The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions?
Push with her glottis open.
Identify the position of the fetus whose buttocks are in the fundus, whose fetal back is on the maternal right side between the midline, and lateral surface of the abdomen, and whose attitude is general flexion.
ROA
When performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. What is the fetal position?
ROA
A client who is 38 weeks pregnant presents to the labor unit for a nonstress test (NST). The resulting fetal monitor strip is shown. How does the nurse interpret this finding?
Reassuring; fetal heart rate accelerates with movement
A nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect?
Rectal pressure during contractions
A nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first?
Reposition her on her left side.
A laboring client has asked the nurse to help her use a nonpharmacological strategy for pain management. Name the sensory simulation strategy.
Selecting a focal point and beginning breathing techniques
A nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client?
Semi-Fowler position to avoid hypotension
A client at 42 weeks' gestation is scheduled for induction of labor. The nurse starts the induction with a piggyback infusion of 15 units of oxytocin (Pitocin). What clinical finding requires the nurse to discontinue the oxytocin infusion?
Several late fetal heart rate decelerations that return to baseline after the contraction is over
A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, "I can't take this a minute longer." What does this behavior indicate to the nurse caring for her?
She is entering the transition phase of labor.
A nurse is assessing a pregnant client during the third trimester. What clinical finding is an expected response in later stages of pregnancy?
Shortness of breath on exertion
A nurse is conducting the admission assessment of a client who is positive for Group B Streptococcus (GBS). Which finding is of most concern to the nurse?
Spontaneous rupture of membranes 3 hours ago
The transmission of which microorganism that causes maternal mastitis is minimized by frequent hand washing by nursing staff members?
Staphylococcus aureus
The gravida 1 now para 1 woman delivered a 7-lb 6-oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks the baby be picked up so she can take a nap. What behavior is the new mother demonstrating?
Taking-in
A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" What knowledge must the nurse have before responding?
The cervix dilates and becomes effaced in true labor.
A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor?
The cervix is dilated.
A nurse is caring for a client during the transition phase of labor. The nurse determines that the client has entered the second stage of labor when:
The client reports that she feels the urge to move her bowels.
A pregnant client in the third trimester tells the nurse in the prenatal clinic that she has heartburn after every meal. What explanation should the nurse give about the cause of the heartburn?
The esophageal sphincter relaxes and allows acid to be regurgitated.
The health care provider completes the vaginal examination by determining that the presenting part of the fetus is at -1 station. What does this information mean?
The head is 1 cm above the ischial spines
During a routine visit to the prenatal clinic a client listens to the fetal heartbeat for the first time. The client, commenting on how rapid it is, appears frightened and asks whether this is normal. The nurse should explain:
The heart rate is usually rapid, and this one is in the expected range."
A 36-year-old primigravida, accompanied by her husband, is admitted to the birthing unit at 39 weeks' gestation. External fetal monitoring is instituted. What should the nurse consider when a fetus is being monitored?
The machinery may be frightening to a laboring couple.
What should a nurse include in the discharge teaching of a postpartum client?
The prenatal Kegel tightening exercises should be continued.
A pregnant client asks the clinic nurse how smoking will affect her baby. What information about cigarette smoking will influence the nurse's response?
The resulting vasoconstriction affects both fetal and maternal blood vessels.
A pregnant client is asking the nurse when she will gain the most weight. At which time during prenatal development should the nurse tell the client to expect the greatest fetal and maternal weight gain?
Third trimester
A 42-year-old client at 39 weeks' gestation has a reactive non-stress test (NST). What should the nurse explain to the client about the positive result?
This is the desired response at this stage of gestation.
A nurse examines a client who had a cesarean birth. It has been 3 days since the birth and the client is about to be discharged. Where does the nurse expect the fundus to be located?
Three finger breadths below the umbilicus
Immediately after the third stage of labor a nurse administers the prescribed oxytocin (Pitocin) infusion. Why is this medication administered?
To help the uterus contract
During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. What should the nurse advise the client about her position when she sleeps?
Turn from side to side."
As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and says she feels as if she is going to faint even though she is lying flat on her back. What should the nurse do?
Turn her onto her left side
A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first?
Turn the oxytocin infusion off.
During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction?
Turning the client on her side
The nurse is interpreting the results of a non-stress test (NST) on a client at 41 weeks' gestation. Which result after 20 minutes is suggestive of fetal reactivity? ]
Two accelerations of 15 beats/min lasting 15 seconds
Five minutes after a birth the nurse-midwife determines that the client's placenta is separating. What indicates that this is occurring?
Umbilical cord lengthens
Why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor?
Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia.
Before a postpartum client is discharged, the nurse advises her about problems that should be reported and then asks her to recall these problems. Identification of which problem identified by the client indicates that the teaching has been effective?
Urgency, frequency, and burning on urination
A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse tell the client to do?
Use the pant-breathing pattern.
A client arrives in the birthing room with the fetal caput emerging. What should the nurse say to the client during a contraction?
Use the panting-breathing pattern."
In a childbirth preparation class the instructor teaches the women to control their urge to push until the cervix is fully dilated. Which action does the nurse teach that will help control the urge to push?
Using panting and blowing breathing patterns
What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor?
Uterine tetany
During a prenatal visit, a client at 37 weeks' gestation tells a nurse that she has painful, irregular contractions. What should the nurse recommend?
Walking around until they subside
A client on her first prenatal clinic visit is at 6 weeks' gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond?
What activities does your job entail?"
A client at 38 weeks' gestation is scheduled for a nonstress test. The woman asks the nurse, "Do you think this test is necessary?" How should the nurse reply?
You seem to have doubts about this test.
During a counseling discussion of nutrition, a nurse explains to a pregnant client that she will need additional calcium during pregnancy and that the best source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." What is the nurse's best reply?
Your practitioner can prescribe calcium supplements."
Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?
blowing
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record?
first
A client who is pregnant for the first time asks the nurse about the changes in her body. While describing the changes in each body system, the nurse mentions that the system that undergoes the
most profound change of all during pregnancy is the:
A client who is at 13 weeks' gestation arrives at the emergency department. She states that she began to have spotting and a small amount of vaginal bleeding several hours ago. This is her second pregnancy. What parity should the nurse record?
multigravida
A vaginal examination reveals that a client in labor is dilated 8 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering?
transition
A primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the:
Anterior pituitary gland
The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located?
Below the ischial spines
After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones?
Below the umbilicus on the right side
While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation and lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?
G5 T1 P1 A2 L2
A multigravida has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time?
Halfway between the symphysis pubis and the umbilicus
The nurse is caring for a gravida 2 para 2 client who gave birth the previous day. During the morning assessment the nurse notes that the lochia is rubra and moderately heavy. The picture indicates where the fundus is located. What should the nurse do next?
Have the woman void and reassess.
The nurse is caring for a client whose labor is to be induced. What is the nurse's responsibility when a client's labor is being stimulated with an oxytocin (Pitocin) infusion?
Stopping the infusion if contractions become hypertonic
A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?
Take a walk around the unit with her
A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client reports that she is going to vomit. What phase of the first stage of labor does the nurse suspect the client has entered?
Transition
A pregnant client uses a computer almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend?
Try to walk around every few hours during the workday."
At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?
Uteroplacental insufficiency
A nurse is caring for a client during the early postpartum period. The client alerts the nurse that she is experiencing pain. The nurse interviews the client, obtains her vital signs, and performs a physical assessment. What does this assessment most likely reveal?
Vaginal hematoma
A nurse assesses the frequency of a client's contractions by timing them from the beginning of a contraction until the:
Beginning of the next contraction
A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100% effaced and dilated 3 cm. The fetal head is at +1 station. In what area of the client's pelvis is the fetal occiput?
Below the ischial spines
A client is admitted in active labor. The nurse, performing Leopold maneuvers, determines that the fetus is in the left occiput anterior (LOA) position. Where should the nurse place the transducer of the electronic fetal monitor?
Left lower quadrant
The coach of a primigravida who has been in active labor for about 6 hours asks the nurse, "How much longer will this take? She's having a lot of back pain, and she's so uncomfortable." How should the nurse respond?
Let me show you how to apply back pressure."
A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear?
Low-heeled shoes
