Intrapartum
A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: 1 cm above the ischial spine 1 fingerbreadth below the symphysis pubis 1 inch below the coccyx 1 inch below the iliac crest
1 cm above the ischial spine
A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. 1. Stop of Pitocin infusion 2. Perform a vaginal examination 3. Reposition the client 4. Check the client's blood pressure and heart rate 5. Administer oxygen by face mask at 8 to 10 L/min 1, 2, 3, 4, 5 1, 4, 2, 3, 5 1, 4, 3, 5, 2 1, 2, 4, 5, 3
1, 4, 3, 5, 2
A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly? Preparatory phase Latent phase Active phase Transition phase
Active phase
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: Place the mother in the supine position Document the findings and continue to monitor the fetal patterns Administer oxygen via face mask Increase the rate of pitocin IV infusion
Administer oxygen via face mask
When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: An acceleration An early elevation A sonographic motion A tachycardic heart rate
An acceleration
A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? Identifying the types of accelerations Assessing the baseline fetal heart rate Determining the frequency of the contractions Determining the intensity of the contractions
Assessing the baseline fetal heart rate
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: Auscultating the fetal heart Taking an obstetric history Asking the client when she last ate Ascertaining whether the membranes were ruptured
Auscultating the fetal heart
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: Not yet engaged Entering the pelvic inlet Below the ischial spines Visible at the vaginal opening
Below the ischial spines
After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: Above the umbilicus at the midline Above the umbilicus on the left side Below the umbilicus on the right side Below the umbilicus near the left groin
Below the umbilicus on the right side
The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: Blowing Slow chest Shallow Accelerated-decelerated
Blowing
When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: Stop the oxytocin infusion Change the client's position Prepare for immediate delivery Take the client's blood pressure
Change the client's position
A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: Exhaustion Fear of losing control Involuntary grunting Valsalva's maneuver
Fear of losing control
Fetal presentation refers to which of the following descriptions? Fetal body part that enters the maternal pelvis first Relationship of the presenting part to the maternal pelvis Relationship of the long axis of the fetus to the long axis of the mother A classification according to the fetal part
Fetal body part that enters the maternal pelvis first
A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? Fetal heart rate of 180 beats per minute White blood cell count of 12,000 Maternal pulse rate of 85 beats per minute Hemoglobin of 11.0 g/dL
Fetal heart rate of 180 beats per minute
Which measure would be least effective in preventing postpartum hemorrhage? Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered Encourage the woman to void every 2 hours Massage the fundus every hour for the first 24 hours following birth Teach the woman the importance of rest and nutrition to enhance healing
Massage the fundus every hour for the first 24 hours following birth
A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? Keeping the significant other informed of the progress of the labor Providing comfort measures Monitoring fetal heart rate Changing the client's position frequently
Monitoring fetal heart rate
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? Encourage the client's coach to continue to encourage breathing exercises Encourage the client to continue pushing with each contraction Continue monitoring the fetal heart rate Notify the physician or nurse midwife
Notify the physician or nurse midwife
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? Prepare the client for an ultrasound Obtain equipment for external electronic fetal heart monitoring Obtain equipment for a manual pelvic examination Prepare to draw a Hgb and Hct blood sample
Obtain equipment for a manual pelvic examination
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: Breech Transverse Occiput anterior Occiput posterior
Occiput posterior
A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor? Gender of the fetus Fetal position Labor progress Oxygenation
Oxygenation
A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? Medication that will provide sedation Increased hydration Oxytocin (Pitocin) infusion Administration of a tocolytic medication
Oxytocin (Pitocin) infusion
A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: Noting if the heart rate is greater than 140 BPM Placing the diaphragm of the Doppler on the mother abdomen Performing Leopold's maneuvers first to determine the location of the fetal heart Palpating the maternal radial pulse while listening to the fetal heart rate
Palpating the maternal radial pulse while listening to the fetal heart rate
A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? A loud mouth Low self-esteem Hemorrhage Postpartum infections
Postpartum infections
A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: Over the fetus that is most anterior to the mother's abdomen Over the fetus that is most posterior to the mother's abdomen So that each fetal heart rate is monitored separately So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus
So that each fetal heart rate is monitored separately
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: Change the woman's position Stop the Pitocin Elevate the woman's legs Administer oxygen via a tight mask at 8 to 10 liters/minute
Stop the Pitocin
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: Trendelenburg's position with the legs in stirrups Semi-Fowler position with a pillow under the knees Prone position with the legs separated and elevated Supine position with a wedge under the right hip
Supine position with a wedge under the right hip
A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should: Transfer her immediately by stretcher to the birthing unit Tell her to breathe through her mouth and not to bear down Instruct the client to pant during contractions and to breathe through her mouth Support the perineum with the hand to prevent tearing and tell the client to pant
Support the perineum with the hand to prevent tearing and tell the client to pant
A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? Swelling of the calf in one leg Prolonged clotting times Decreased platelet count Petechiae, oozing from injection sites, and hematuria
Swelling of the calf in one leg
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: Tell the woman she can rest after she feeds her baby Recognize this as a behavior of the taking-hold stage Record the behavior as ineffective maternal-newborn attachment Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? The client begins to expel clear vaginal fluid The contractions are regular The membranes have ruptured The cervix is dilated completely
The cervix is dilated completely
The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: Until the time it is completely over To the end of a second contraction To the beginning of the next contraction Until the time that the uterus becomes very firm
To the beginning of the next contraction
Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: Uses soap and warm water to wash the vulva and perineum Washes from symphysis pubis back to episiotomy Changes her perineal pad every 2 - 3 hours Uses the peribottle to rinse upward into her vagina
Uses the peribottle to rinse upward into her vagina
A client is admitted to the L & D suite at 36 weeks' gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms? Hysteria compounded by the flu Placental abruption Uterine rupture Dysfunctional labor
Uterine rupture
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? Early decelerations Variable decelerations Late decelerations Short-term variability
Variable decelerations
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? Three contractions occurring within a 10-minute period A fetal heart rate of 90 beats per minute Adequate resting tone of the uterus palpated between contractions Increased urinary output
A fetal heart rate of 90 beats per minute
A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? The umbilical cord shortens in length and changes in color A soft and boggy uterus Maternal complaints of severe uterine cramping Changes in the shape of the uterus
Changes in the shape of the uterus
The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: Clear and dark amber in color Milky, greenish yellow, containing shreds of mucus Clear, almost colorless, and containing little white specks Cloudy, greenish-yellow, and containing little white specks
Clear, almost colorless, and containing little white specks
An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: Complete bed rest for the remainder of the pregnancy Delivery of the fetus Strict monitoring of intake and output The need for weekly monitoring of coagulation studies until the time of delivery
Delivery of the fetus
A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? Document the findings and tell the mother that the monitor indicates fetal well-being Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen Notify the physician or nurse midwife of the findings Reposition the mother and check the monitor for changes in the fetal tracing
Document the findings and tell the mother that the monitor indicates fetal well-being
Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? Fetal presenting part is 1 cm above the ischial spines Effacement is 4 cm from completion Dilation is 50% completed Fetus has achieved passage through the ischial spines
Fetal presenting part is 1 cm above the ischial spines
A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? Hypotonic contractions Forceps delivery Schultz delivery Weak bearing down efforts
Forceps delivery
Parents can facilitate the adjustment of their other children to a new baby by: Having the children choose or make a gift to give to the new baby upon its arrival home Emphasizing activities that keep the new baby and other children together Having the mother carry the new baby into the home so she can show the other children the new baby Reducing stress on other children by limiting their involvement in the care of the new baby
Having the children choose or make a gift to give to the new baby upon its arrival home
A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: A form of biofeedback to enhance bearing down efforts during delivery Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus The application of pressure to the sacrum to relieve a backache Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest
Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus
Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors? Contractions, passageway, placental position and function, pattern of care Contractions, maternal response, placental position, psychological response Passageway, contractions, placental position and function, psychological response Passageway, placental position and function, paternal response, psychological response
Passageway, contractions, placental position and function, psychological response
A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond? Let the client get up to use the potty Allow the client to use a bedpan Perform a pelvic examination Check the fetal heart rate
Perform a pelvic examination
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? Place the client in Trendelenburg's position Call the delivery room to notify the staff that the client will be transported immediately Gently push the cord into the vagina Find the closest telephone and stat page the physician
Place the client in Trendelenburg's position
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: Monitor the Pitocin infusion closely Provide pain relief measures Prepare the client for an amniotomy Promote ambulation every 30 minutes
Provide pain relief measures
A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? Absence of abdominal pain A soft abdomen Uterine tenderness/pain Painless, bright red vaginal bleeding
Uterine tenderness/pain
During the period of induction of labor, a client should be observed carefully for signs of: Severe pain Uterine tetany Hypoglycemia Umbilical cord prolapse
Uterine tetany
A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? Placing the client on complete bed rest Continuous electronic fetal monitoring An IV infusion of antibiotics Placing a code cart at the client's bedside
Continuous electronic fetal monitoring
Which of the following observations indicates fetal distress? Fetal scalp pH of 7.14 Fetal heart rate of 144 beats/minute Acceleration of fetal heart rate with contractions Presence of long term variability
Fetal scalp pH of 7.14
A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? Disseminated intravascular coagulation Chronic hypertension Infection Hemorrhage
Hemorrhage
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: Severe postpartum headache Limited perception of bladder fullness Increase in respiratory rate Hypotension
Hypotension
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: Less pressure on her cervix Increased efficiency of contractions Decreased number of contractions The need for increased maternal blood pressure monitoring
Increased efficiency of contractions
A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: Hematoma Placenta previa Uterine atony Placental separation
Placental separation
At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: Discontinue the catheter, if the reading is not above 80% Discontinue the catheter, if the reading does not go below 30% Advance the catheter until the reading is above 90% and continue monitoring Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: Express a strong need to review events and her behavior during the process of labor and birth Exhibit a reduced attention span, limiting readiness to learn Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn Have reestablished her role as a spouse/partner
Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn
Which of the following findings meets the criteria of a reassuring FHR pattern? FHR does not change as a result of fetal activity Average baseline rate ranges between 100 - 140 BPM Mild late deceleration patterns occur with some contractions Variability averages between 6 - 10 BPM
Variability averages between 6 - 10 BPM
Which of the following fetal positions is most favorable for birth? Vertex presentation Transverse lie Frank breech presentation Posterior position of the fetal head
Vertex presentation
A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she: Will not feel the episiotomy May lose bladder sensation May lose the ability to push Will no longer feel contractions
Will not feel the episiotomy
