Intrapartum

The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation?

"It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity."

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client?

Assess for signs and symptoms of labor

The 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 electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate.

The nurse assist the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure?

Assess the fetal heart rate

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action?

Assess the vagina and cervix with a gloved hand.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin.

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client?

Breathe rapidly.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?

Continue to monitor the client.

The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?

Continue to monitor the client.

The 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 action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action?

Explain to the client why a cesarean delivery is necessary.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior?

Fear of losing control

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?

Fetal heart rate of 180 beats/minute

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted?

Painless vaginal bleeding

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention?

Provide pain relief measures

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine tenderness

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action?

Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?

Delivery of the fetus

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations?

Encourage an upright or side-lying maternal position

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate?

Every 15 minutes

Which assessment following an amniotomy should be conducted first?

Fetal heart rate pattern

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred?

Forceps delivery

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?

Hypotonic

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal?

Pale straw in color, with flecks of vernix

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?

The passage of meconium

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply.

- Increase in fundal height - Hard, boardlike abdomen - Persistent abdominal pain

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply.

- Keep the room semi-dark. - Initiate seizure precautions. - Pad the side rails of the bed. - Avoid environmental stimulation.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply

-Tachycardia -Fetal hypoxia -Metabolic acidemia -Congenital anomalies

The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? Click on the image to indicate your answer.

1

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

1. Increased efficiency of contractions 2. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply.

1. Petechiae . 2.Hematuria 4. Prolonged clotting times 5. Oozing from injection sites

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer.

3

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued?

A fetal heart rate of 90 beats/minute

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

A gravida II who has just been diagnosed with dead fetus syndrome A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action?

Clear and maintain an open airway.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement?

Administer oxygen at 8-10 L/min via face mask

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency?

Butorphanol tartrate

A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action?

Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP).

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention?

Complaints of sever abdominal pain

The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion?

Continuous electronic fetal monitoring

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client?

Measure fundal height.

The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved?

Moderate variability present

The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

Monitoring fetal status

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia?

Monitoring the mother's blood pressure

The 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 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP).

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately?

Palpating the maternal radial pulse while listening to the FHR

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

Place the client in Trendelenburg's position.

The 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 which condition?

Placental separation

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome?

Prevent dehydration and hypoxemia.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply.

StationDilationEffacement

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

The cervix is dilated completely. The spontaneous urge to push is initiated from perineal pressure.

The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time?

The client's fear

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action?

Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min.

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the health care provider (HCP)? Select all that apply.

Thick white amniotic fluid with no odorLight green amniotic fluid with no odorClear, dark amber amniotic fluid

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply.

Uterine tendernessAcute abdominal painA hard, "boardlike" abdomenIncreased uterine resting tone on fetal monitoring

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action?

Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.