intrapartum period
A client comes to the labor unit reporting contractions. After gathering data, it is determined the client is having Braxton Hicks contractions, and education regarding the difference between true and false labor is given. Which statement by the client indicates the teaching has been effective?
"Braxton Hicks contractions begin in the abdomen and remain irregular."
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."
A client in the early stages of labor asks the nurse whether it's really necessary for her to purchase a car seat, noting that they're very expensive. Which response by the nurse is best?
"The only way to safely transport your baby in a car is to have him restrained securely in a car seat."
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?
"What is your expected due date?"
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?
"What is your expected due date?"
A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response?
"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."
A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has an intravenous infusion of oxytocin running. Which response by the nurse would be best?
"You may use the bathroom with my assistance."
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.
-Establish trust with the client. -Explore the client's coping behaviors. -Keep client informed about progress and procedures.
The nurse is caring for a client in labor. Which findings would prompt the nurse to notify the health care provider? Select all that apply.
-The client's membranes rupture, and the amniotic fluid is green. -Late decelerations are noted on the external fetal monitor strip.
A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply.
-Use the hospital code for HIV when documenting care. -Ask all family members, except the client's significant other, to wait outside when she's educating the client.
A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.
-check vital signs -check the fundal height -notify rn
A pregnant client is at term and in labor. The nurse is checking the fetal heart rate. Which finding would the nurse interpret as indicating appropriate fetal perfusion?
135 beats/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.
When assessing the fetal heart rate tracing of a client in labor, the nurse assesses the fetal heart rate at 170 beats/minute. What should the nurse do first?
Administer oxygen to the client.
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?
An increased sense of rectal pressure
A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?
Ask the client about her most recent blood glucose levels.
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?
Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.
A client who's in active labor is yelling, "Get out of here!" As the nurse enters the client's room, she notices the client's estranged husband in the room. How should the nurse intervene?
Ask the husband to leave or phone security.
A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best?
Assisting the client to ambulate in the room
When caring for a client during the second stage of labor, which action would be most appropriate?
Assisting the mother with pushing
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?
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?
Change the client's position.
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
Change the client's position.
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.
A nurse is observing the external fetal monitoring strip (shown) of a client who is in labor. Which nursing interventions should the nurse implement?
Continue to monitor the fetal heart rate.
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.
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?
Encourage the client to practice breathing exercises to decrease the urge to push.
The third stage of labor ends after the birth of the placenta. Which action should the nurse take immediately following the birth of the placenta?
Examine the placenta for completeness.
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.
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
A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?
Fetal heart rate variability within an acceptable range
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
A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be effective for the couple at this time?
Instruct the husband on touch, massage, and breathing patterns.
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.
Which intervention should be included in the safety plan for the maternal- infant unit?
Making sure that the spouse or significant other wears an identification band
A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next?
Massage the fundus.
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 take which of the following actions?
Notify the obstetrician
Cervical effacement and dilation aren't progressing for a client in labor. The health care provider orders IV administration of oxytocin. Which rationale does the nurse give the client for the close monitoring of her fluid intake and urine output?
Oxytocin causes water intoxication.
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What should the nurse do next?
Prepare for immediate delivery of the baby
A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client?
Prepare the client and partner for a cesarean birth as soon as possible.
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?
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?
Provide helpful distractions.
A client in the active phase of labor has a reactive fetal monitor strip and has been encouraged to walk. When the client's membranes rupture and the fetal cord is observed in the vaginal canal, what is the priority action by the nurse?
Put the client in a knee-chest position.
The nurse is caring for a client in the second stage of labor. The client provided the healthcare team with a birth plan that included no use of analgesia. The client is having strong contractions with pain at 10 out of 10 and asks for something for pain. What is the nurse's best action?
Remind the client of the desire outlined in the birth plan and clarify if analgesia is desired.
A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take?
Reposition the client to left lateral position.
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?
Stop the magnesium sulfate infusion.
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 160/90, pulse 92, respiration 22, temperature 99.1, and positive proteinuria
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?
blood pressure of 146/94 mm Hg
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?
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?
date of last menstrual period (LMP)
A nurse is assisting in monitoring a client in labor. Which data obtained by the nurse is indicative of fetal well-being?
fetal heart rate of 145 to 155 beats/minute with 15-second accelerations to 160
A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding?
fetal heart rate of 80 beats/minute
A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered?
lateral
A pregnant client at term is in the first stage of labor and has an electronic fetal monitoring (EFM) device in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion?
moderate variability
A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section?
physician
A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which best describes why the nurse is asking questions about the family's birth plan?
recognizing the family as active participants in their care
The nurse is reviewing information about the stages of labor with a pregnant client. The nurse determines that the client has understood the information when stating that crowning occurs during which stage of labor?
second
A client is admitted to the labor unit in early labor. The nurse would encourage the client to assume which position to promote tissue perfusion? 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?
side-lying