Intrapartum
The nurse admits a client in active labor at 38 weeks gestation. The client says to the nurse, "I was not expecting to go into labor so soon, so I did not have time to shave down there." How should the nurse respond? "It is your choice. It can make it much easier to keep the perineal area clean during labor and in the postpartum period." "We do not recommend shaving the pubic area, because it greatly increases the risk of perineal infections. But it is your choice." "There is no medical reason for shaving the pubic area for the birth, so you don't need to worry about it." "It is not medically necessary and is based on the client's preference. Would shaving make you more comfortable?"
"It is not medically necessary and is based on the client's preference. Would shaving make you more comfortable?"
The nurse is obtaining information from a pregnant client who is at 38 weeks' gestation and believes that she is going into labor. Which statement made by the client should be immediately reported to the health care provider? "My membrane ruptured 2 days ago." "I expelled a mucous plug yesterday." "I had a previous miscarriage 4 years ago during my first trimester." "I have had indigestion during my pregnancy."
"My membrane ruptured 2 days ago."
The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent? Influence of the extended family Gender identity Religious beliefs Patterns of verbal communication
Influence of the extended family
The nurse caring for a primipara in late first stage of labor notes left occiput-anterior (LOA) position, 7 cm dilated, and at +2 station. Which finding should be reported to the health care provider? Labor is progressing well. Client is ready to deliver immediately. Fetal head is big and preventing descent. A cesarean section is required.
Labor is progressing well.
A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response? stimulates labor and prevents hemorrhage decreases maternal heart rate and stimulates labor slows labor progression and increases diuresis prevents hemorrhage and increases diuresis
stimulates labor and prevents hemorrhage
A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion? 39 drops/minute 31 drops/minute 35 drops/minute 42 drops/minute
42 drops/minute
The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN? A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit. A client in the third stage of labor with a moderate amount of blood trickling in a steady stream. A client in the second stage of labor who is requesting to go the bathroom. A client who is in the fourth stage of labor with fundus above the umbilicus and bleeding with moderate amount of clots
A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.
A client has received dinoprostone to help ripen her cervix. What should the nurse do to determine effectiveness of the drug? Monitor urinary output. Assess for ripening and softening of the cervix. Assess for resting period under 2 minutes between contractions. Assess for rupture of membrane.
Assess for ripening and softening of the cervix.
The nurse is caring for a 28-year-old primigravida who is reporting severe back labor. Which nursing intervention is most effective in improving the comfort of the client? Patterned childbirth breathing Epidural analgesia Hydrotherapy Back massage with sacral pressure
Back massage with sacral pressure
A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in the fetal heart rate (FHR). After notifying the registered nurse in charge, what should the nurse do next? Administer oxygen. Prepare for emergency cesarean birth. Change the client's position. Check for placenta previa.
Change the client's position.
A client in labor requires an episiotomy. Which complication should the nurse have the client report to the health care provider after the procedure? blood loss uterine disfigurement postpartum hormonal fluctuation prolonged dyspareunia
prolonged dyspareunia
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress? maternal age of 22 years treatment for syphilis at 15 weeks' gestation blood pressure of 146/94 mm Hg maternal weight gain of 30 lb (13.6 kg)
blood pressure of 146/94 mm Hg
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them? the client's partner the client's parents, because they're blood relatives the court system, because the client isn't married and is legally responsible for the neonate the client's best friend, who's the sperm donor
the client's partner
A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? Collaborate with the physician to make a referral to social services. Question the woman in front of her partner. Contact hospital security to escort the partner from the hospital. Tell the partner that to leave because the partner is intimidating the client.
Collaborate with the physician to make a referral to social services.
A nurse identifies meconium in the amniotic fluid of a pregnant client in labor who has had a spontaneous rupture of membranes. The nurse identifies this finding as normal because of which situation? preterm labor cephalopelvic disproportion breech presentation prolonged latent phase
breech presentation
A client in active labor has severe second-degree burns on her buttocks. When questioned about the burns, the client replies, "I was trying to use that hot water thing to help my hemorrhoids." Which statement made by the nurse is therapeutic? "Who told you that you have hemorrhoids?" "Did your doctor order the hot water treatments?" "Did I hear you say you sustained this burns from hot water application to the buttocks?" "I am sorry the hot water did not help the hemorrhoids."
"Did I hear you say you sustained this burns from hot water application to the buttocks?"
The nurse is preparing to admit a client who came to the delivery area in the company of her husband. The client states, "I am in labor and I attended the facility clinic for prenatal care." Which question should the nurse ask her first? "Do you have any chronic illnesses?" "What is your expected due date?" "Do you have any allergies?" "Who will be with you during labor?"
"What is your expected due date?"
Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? Episodes of nausea and vomiting An increased sense of rectal pressure A decrease in intensity of contractions An increase in fetal heart rate variability
An increased sense of rectal pressure
An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? Knowing the client's cultural background, suggest that the family call a meeting to make the decision. Honor the mother's request. Request that an anesthetist administer the epidural because the client is uncomfortable. Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.
Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.
Which care intervention is appropriate for the fourth stage of labor? Observing the perineum for show and bulging Assessing lochia and the location and consistency of the fundus Encouraging rest between contractions Assisting with breathing techniques
Assessing lochia and the location and consistency of the fundus
A client in labor, who attended natural birth classes, is asking for something to relieve the pain. What is the most appropriate action for the nurse to take? Put on the television to distract the client from the pain. Remind the client that medications for pain are not good for the baby. Do nothing because the client will not remember that she requested pain medication. Contact the health care provider, supporting the client until an analgesic is prescribed.
Contact the health care provider, supporting the client until an analgesic is prescribed.
A diabetic client in labor tells the nurse she has been feeling nauseous since her labor started and did not take her insulin even after eating some soup and crackers. One hour later, she reports increased nausea and feeling flushed. The nurse notes a fruity odor to her breath. What do these findings suggest? Hypoglycemia Transition to the active phase of labor Infection Diabetic ketoacidosis
Diabetic ketoacidosis
The nurse-midwife determines that a client is in the second stage of labor and the presenting part is descending rapidly. What action should the nurse take to prevent complications? Leave the client and contact the healthcare provider. Encourage the client to practice breathing exercises to decrease the urge to push. Ask client to tell you about her coping mechanisms for labor Provide update on the clients' progress to the family
Encourage the client to practice breathing exercises to decrease the urge to push.
Which action should the nurse take to promote the descent of the fetus's presenting part? Insert an indwelling urinary catheter. Administer an enema to remove any stool from the rectum. Encourage the client to void every 2 hours. Administer I.V. fluids.
Encourage the client to void every 2 hours.
A client who is induced at 40 weeks' gestation with oxytocin drip is expressing fear and anxiety about the induced labor. Which interventions should the nurse implement? Select all that apply. Reduce the drip if the client reports pain. Allow privacy by leaving the client alone in the room. Establish trust with the client. Explore the client's coping behaviors. Keep client informed about progress and procedures.
Establish trust with the client. Explore the client's coping behaviors. Keep client informed about progress and procedures.
A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response? Explain to the client that the feeling is normal during this stage. Assist the client to the bathroom. Give enema to help the client move the bowel. Tell the client that you will notify the doctor.
Explain to the client that the feeling is normal during this stage.
A client in the first stage of labor is agitated, upset, and crying. The client expressed concern about being in labor for 32 hours the last time she gave birth. Based on this information, the nurse should expect which nursing diagnosis in the client's plan of care? Fear related to a potentially difficult childbirth Compromised family coping related to hospitalization Acute pain related to labor contractions Anxiety related to the facility environment
Fear related to a potentially difficult childbirth
A client with hypotonic labor dysfunction is receiving oxytocin augmentation. Her contractions become more frequent and intense. Dilation progresses to 8 cm, but the fetal head remains at +1 station. The nurse notes a soft bulge just above the symphysis. Which is the best nursing intervention? Help the client urinate. Change the client's position. Reevaluate the fetal presentation. Offer the client an opioid analgesic.
Help the client urinate.
A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be most appropriate? Perform a culture on the discharge, and inform the client that she might have mastitis. Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy. Tell the client that her milk is starting to come in because she's in labor. Complete a thorough breast examination, and document the results in the chart.
Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy.
A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action? Tell the partner that the physician is very busy and will come when available. Ask the partner if there is any family support that can come to the hospital. Notify the physician that the partner has been waiting to discuss the mother's condition. Reassure the partner that the mother's condition is stable at present.
Notify the physician that the partner has been waiting to discuss the mother's condition.
A nurse is caring for a client in active labor who is crying and asking for something for pain. Her medical record shows that she does not tolerate prescribed opioid analgesics. Which of the following nonpharmacologic interventions might be helpful to this client? Encourage the client to drink very cold tea. Provide back massage to the client. Turn on the lights in the room. Administer ibuprofen as ordered.
Provide back massage to the client.
A 23-year-old primigravida client is in the active stage of labor. She and her husband have been using breathing techniques. The husband asks whether he can do anything more to help his wife during labor. What should the nurse suggest? Ask about the progress of other clients. Frequently ask her how she feels. Encourage her to talk during contractions. Provide helpful distractions.
Provide helpful distractions.
A primigravida client with severe gestational hypertension is admitted to the labor unit. She has been receiving magnesium sulfate IV for 3 hours. The latest data reveals deep tendon reflexes (DTRs) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and urine output of 20 mL/ hour. Which action would be most appropriate? Increase the infusion rate by 5 gtt/minute. Stop the magnesium sulfate infusion. Decrease the infusion rate by 5 gtt/minute. Continue monitoring the client.
Stop the magnesium sulfate infusion.
A nurse is caring for a client who is in the third stage of labor. Which activities or behaviors does the nurse anticipate at this stage? Select all that apply. The client delivers the placenta. The client is apprehensive about the process. The client delivers the neonate. The client is excited about the process. The client is feeling embarrassed because she has an urge to defecate. The client is focused on the neonate's condition.
The client is focused on the neonate's condition. The client delivers the placenta.
A nurse is reviewing data for multiple clients in the first stage of labor. Which client should receive priority attention? a client with blood pressure of 110/60, pulse 72, respiration 20, temperature 98.1, and positive proteinuria a client with blood pressure of 120/90, pulse 82, respiration 20, temperature 97.2, and negative proteinuria a client with blood pressure of 160/90, pulse 92, respiration 22, temperature 99.1, and positive proteinuria a client with blood pressure of 150/90, pulse 102, respiration 18, temperature 97.1, and negative protein in urine
a client with blood pressure of 160/90, pulse 92, respiration 22, temperature 99.1, and positive proteinuria
A client in labor is receiving magnesium sulfate as an intravenous infusion. Which medication should the nurse ensure is at the bedside while the magnesium sulfate is being infused? oxytocin calcium gluconate naloxone terbutaline
calcium gluconate
A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. What intervention specific to the client's condition should the nurse anticipate? induction of labor continuous monitoring of fetal heart rate administration of IV antibiotic cesarean delivery
cesarean delivery
A multiparous client admitted to the labor unit has not received prenatal care for this pregnancy. When collecting information from this client, which data would be most important to obtain? name of insurance provider date of last menstrual period (LMP) family history of sexually transmitted diseases (STDs) number of siblings
date of last menstrual period (LMP)
