LE 1 Reviewer (High-Risk Intrapartum)
Serum magnesium level of 9 g/dL.
A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.
Assess the maternal pulse while listening to the fetal heart rate.
A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultates the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. 2. Notify the health care provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask.
4 and 5
A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select all that apply. 1. Change in contraction pattern from q 3 min 90 sec to q 2 min 60 sec. 2. Change in fetal heart pattern from no decelerations to early decelerations. 3. Change in beat-to-beat variability from minimal to moderate. 4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.
1, 2, and 5
A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. 1. Breech presentation. 2. Station -3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie.
"Have you felt the baby move since the membranes broke?"
A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual odor." 3. "Your labor should start very soon." 4. "Have you felt the baby move since the membranes broke?"
Calcium gluconate.
A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).
Coughing and deep breathing.
A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.
Crying and sad.
A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sad. 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.
Diminished short- and long-term variability.
A client with an internal fetal monitor catheter in place has just received IV butorphanol (Stadol) for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Diminished short- and long-term variability. 4. Accelerations after contractions.
Delivery of a healthy baby.
A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.
Turn off the oxytocin infusion.
A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.
Assess the fluid with nitrazine and see if the paper turns blue.
A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? 1. Palpate the woman's bladder to check for urinary retention. 2. Obtain a urine culture to check for a urinary tract infection. 3. Assess the fluid with nitrazine and see if the paper turns blue. 4. Percuss the woman's uterus and monitor for ballottement.
The baby may develop thrush after delivery.
A client, G3 P2002, 40 weeks' gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman? 1. She may need a cesarean delivery. 2. She will be treated with antibiotics during labor. 3. The baby may develop thrush after delivery. 4. The baby will be isolated for at least one day.
Variable fetal heart decelerations.
A client, G3 P2002, is immediately postexternal version. The nurse monitors this client carefully for which of the following? 1. Decreased urinary output. 2. Elevated blood pressure. 3. Severe occipital headache. 4. Variable fetal heart decelerations.
Contraction frequency of 1 minute.
A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.
Abruptio placentae.
A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications? 1. Prolonged labor. 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta.
Fetal monitor tracing shows late decelerations.
A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? 1. Contraction pattern is every 3 min 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90.
Vaginal examination.
A full-term client, contracting every 15 min 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time?1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.
Notify the physician of her request.
A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.
Assess cervical dilation.
A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question? 1. Administer betamethasone (Celestone) 12 mg IM daily times 2. 2. Maintain strict bed rest. 3. Assess cervical dilation. 4. Regulate intravenous (Ringer's lactate: drip rate to 150 mL/hr).
Provide chest compressions at a depth of at least 2 inches.
A laboring woman, who has developed an apparent amniotic fluid embolism, is not breathing and has no pulse. In addition to calling for assistance, which of the following actions by the nurse, who is alone with the patient, is appropriate at this time? 1. Perform cardiac compressions and breaths in a 15 to 2 ratio. 2. Provide chest compressions at a depth of at least 2 inches. 3. Compress the chest at the lower 1⁄2 of the sternum. 4. Provide rescue breaths over a 10-second time frame.
Client has no grand mal seizures.
A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output is 30 mL/hr. 3. Respiratory rate is 16 rpm. 4. Client has no grand mal seizures.
1, 2, and 3
A nurse has been assigned to circulate during the cesarean section of triplets. Which of the following actions should the nurse take before the birth of the babies? Select all that apply. 1. Count the number of sterile sponges. 2. Document the time of the first incision. 3. Notify the pediatric staff. 4. Perform a sterile scrub. 5. Assemble the sterile instruments.
3 and 4
A nurse is caring for a gravid client who is G1 P0000, 35 weeks' gestation. Which of the following would warrant the nurse to notify the woman's health care practitioner that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds.
Uterine resting tone.
A nurse is monitoring a client who is receiving an amnioinfusion. Which of the following assessments is critical for the nurse to make to prevent a serious complication related to the procedure? 1. Color of the amniotic fluid. 2. Maternal blood pressure. 3. Cervical effacement. 4. Uterine resting tone.
Change in fetal heart rate from 128 to 102 bpm.
A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4°F.
Notify the practitioner.
A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the practitioner. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.
Endotracheal tube insertion.
A physician has given a nurse a verbal order to apply cricoid pressure. Which of the following is the likely indication for the action? 1. Forceps delivery. 2. Endotracheal tube insertion. 3. Epidural insertion. 4. Third stage of labor.
Left sacral posterior position.
A physician has notified the labor and delivery suite that four clients will be admitted to the unit. The client with which of the following clinical findings would be a candidate for an external version? 1. +3 station. 2. Left sacral posterior position. 3. Flexed attitude. 4. Rupture of membranes for 24 hours.
The baby is at high risk for neonatal sepsis.
A physician writes the following order—Administer ampicillin 1 g IV q 4 h until delivery—for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal bacteria at 36 weeks' gestation. Which of the following is a rationale for this order? 1. The client is at high risk for chorioamnionitis. 2. The baby is at high risk for neonatal sepsis. 3. The bacterium is sexually transmitted. 4. The bacterium causes puerperal sepsis.
The previous uterine incisions were vertical.
A pregnant woman, G3 P2002, had her two other children by cesarean section. Which of the following situations would mandate that this delivery also be by cesarean? 1. The woman refuses to have a regional anesthesia. 2. The woman is postdates with intact membranes. 3. The baby is in the occiput posterior position. 4. The previous uterine incisions were vertical.
"To help to mature your baby's lungs."
A preterm labor client, 30 weeks' gestation, who ruptured membranes 4 hours ago, is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: 1. "To help to stop your labor contractions." 2. "To prevent an infection in your uterus." 3. "To help to mature your baby's lungs." 4. "To decrease the pain from the contractions."
Monitor for onset of labor.
A primigravid client received Cervidil (dinoprostone) for induction 8 hours ago. The Bishop score is now 10. Which of the following actions by the nurse is appropriate? 1. Perform nitrazine analysis of amniotic fluid. 2. Report abnormal findings to the obstetrician. 3. Place woman on her side. 4. Monitor for onset of labor.
Administer oxygen.
A woman being induced with oxytocin (Pitocin) is contracting every 3 min 30 seconds. Suddenly the woman becomes dypsneic and cyanotic, and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.
Assess the fetal heart rate after each contraction.
A woman has been in the second stage of labor for 21/2 hours. The fetal head is at +4 station and the fetal heart is showing mild late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time? 1. Obtain a consent for the use of forceps. 2. Encourage the woman to push between contractions. 3. Assess the fetal heart rate after each contraction. 4. Advise the woman to refuse the use of forceps.
Narcan (naloxone).
A woman in active labor received Nubain (nalbuphine hydrochloride) 14 mg IV for pain relief. One half hour later her respirations are 8 rpm. The nurse reports the respiratory rate to the physician. Which of the following medications would be appropriate for the physician to order at this time? 1. Narcan (naloxone). 2. Reglan (metoclopramide). 3. Benadryl (diphenhydramine). 4. Vistaril (hydroxyzine).
Duration of contractions of 130 seconds.
A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations.
Low urinary output.
A woman, 32 weeks' gestation, contracting every 3 min 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.
Follow standard infectious disease precautions.
A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.
Monitor her labor.
A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop her infusion. 2. Give her oxygen. 3. Change her position. 4. Monitor her labor.
Late fetal heart decelerations.
A woman, G3 P2002, 42 weeks' gestation, is admitted to the labor suite for induction. A biophysical profile (BPP) report on the client's chart states BPP score of 6 of 10. The nurse should monitor this client carefully for which of the following? 1. Maternal hypertension. 2. Maternal hyperglycemia. 3. Increased fetal heart variability. 4. Late fetal heart decelerations.
Provide the woman with ongoing labor support.
A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.
The cord is prolapsed.
The health care practitioner performed an amniotomy 5 minutes ago on a client, G3 P1011, 40 weeks' gestation, -4 station, and ROP position. The fetal heart rate is 140 with variable decelerations. The fluid is green tinged and smells musty. The nurse concludes that which of the following situations is present at this time? 1. The fetus is post-term. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.
G1 P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm.
The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL. 2. G2 P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1 P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2 P1001, 39 weeks, Rh-negative, today's hematocrit 31%.
Explain all procedures slowly and carefully.
The nurse identifies the following nursing diagnosis for a client undergoing an emergency cesarean section: Risk for ineffective individual coping related to emergency procedure. Which of the following nursing interventions would be appropriate in relation to this diagnosis? 1. Apply antiembolic boots bilaterally. 2. Explain all procedures slowly and carefully. 3. Administer an antacid per MD orders. 4. Monitor the FH and maternal vital signs.
"I'll keep trying until I find the heartbeat."
The nurse is admitting a 38-week-gestation client in labor. The nurse is unable to find the fetal heartbeat with a Doppler. Which of the following comments by the nurse would indicate that the nurse is in denial? 1. "I'll keep trying until I find the heartbeat." 2. "I am sure it is the machine. If I change the battery, I'm sure it will work." 3. "I am so sorry. I am not able to find your baby's heartbeat." 4. "Sometimes I really hate these machines."
1 and 5
The nurse is admitting four full-term primigravid clients to the labor and delivery unit. The nurse requests pre-cesarean section orders from the health care practitioner for which of the clients? The client who has: Select all that apply. 1. Cervical cerclage. 2. FH 156 with beat-to-beat variability. 3. Maternal blood pressure of 90/60. 4. Full effacement. 5. Active herpes simplex 2
3, 4, and 5
The nurse is assessing the Bishop score on a postdates client. Which of the following measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilation. 4. Fetal station. 5. Cervical position.
Risk for impaired skin integrity.
The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? 1. Risk for impaired skin integrity. 2. Risk for body image disturbance. 3. Risk for impaired parenting. 4. Risk for ineffective sexuality pattern.
Signs of preterm labor.
The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick count assessments.
Late decelerations.
The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? 1. Late decelerations. 2. Hyperthermia. 3. Hypotension. 4. Early decelerations.
Increase the intravenous infusion rate.
The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler's position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.
Multigravida with late decelerations.
The physician has ordered Prepidil (dinoprostone) for four gravidas at term. The nurse should question the order for which of the women? 1. Primigravida with Bishop score of 4. 2. Multigravida with late decelerations. 3. G1 P0000 contracting every 20 minutes 30 seconds. 4. G6 P3202 with blood pressure 140/90 and pulse 92.
Primigravida with a transverse lie.
The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.
Age 25, G4 P3003, last delivery by cesarean section.
There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3 P0020, in active labor. 2. Age 22, G1 P0000, eclampsia. 3. Age 25, G4 P3003, last delivery by cesarean section. 4. Age 32, G2 P0100, first baby died during labor.
3 and 4
Which of the following situations in a fully dilated client is incompatible with a forceps delivery? Select all that apply. 1. Maternal history of asthma. 2. Right occiput posterior position at +4 station. 3. Transverse fetal lie. 4. Fetal heart rate of 60 beats per minute at -1 station. 5. Maternal history of cerebral palsy.
1, 4, and 5
A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.
Elevated alanine transaminase (ALT).
A 40-week-gestation client has an admitting platelet count of 90,000 cells/mm3 and a hematocrit of 29%. Her lab values 1 week earlier were platelet count 200,000 cells/mm3 and hematocrit 37%. Which additional abnormal lab value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. 4. Elevated alanine transaminase (ALT).
Diarrhea and back pain.
A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.
LMA (left mentum anterior).
A baby is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. LMA (left mentum anterior). 2. LSP (left sacral posterior). 3. RScT (right scapular transverse). 4. ROP (right occiput posterior).
Magnesium sulfate.
A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order?1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.
Presence of abdominal pain.
A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.
Audible rales.
A 30-year-old G2 P0010 in preterm labor is receiving nifedipine (Procardia). Which of the following maternal assessments noted by the nurse must be reported to the health care practitioner immediately? 1. Heart rate of 100 bpm. 2. Wakefulness. 3. Audible rales. 4. Daily output of 2,000 mL.
Check the fetal heart rate of a client who just ruptured membranes.
A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.
Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth.
A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? 1. Obtain an order from the obstetrician to prepare the client for cesarean delivery. 2. Obtain an order from the obstetrician to administer intravenous ampicillin during labor and the immediate postpartum. 3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. 4. Obtain an order from the pediatrician to place the baby in isolation after delivery.
Station of -3.
After a multiparous woman has been in active labor for 15 hours, an ultrasound is done. The results state that the obstetric conjugate is 10 cm and the suboccipitobregmatic diameter is 10.5 cm. Which of the following labor findings is related to these results? 1. Full dilation of the cervix. 2. Full effacement of the cervix. 3. Station of -3. 4. Frequency every 5 minutes.
The woman has had surgery for scoliosis.
An anesthesiologist informs the nurse that a woman scheduled for cesarean section will have the procedure under general anesthesia with postoperative patient-controlled analgesia rather than under continuous epidural infusion. Which of the following would warrant this decision? 1. The woman has a history of drug addiction. 2. The woman is allergic to morphine sulfate. 3. The woman is a thirteen-year-old adolescent. 4. The woman has had surgery for scoliosis.
The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug.
An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 3. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature.
Flex the woman's thighs sharply toward her abdomen.
During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.
Through the rectal sphincter.
During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record? 1. Into the musculature of the buttock. 2. Through the urinary meatus. 3. Through the rectal sphincter. 4. Into the head of the clitoris.
3 and 4
Four women request to labor in the hospital bathtub. In which of the following situations is the procedure contraindicated? Select all that apply. 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with meconium-stained fluid. 5. Woman with fetus in the occiput posterior position.
Put the client in the knee-chest position.
Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee-chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.
Risk for fetal injury related to possible intrauterine hypoxia.
The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations to 100 bpm. The nurse notes a moderate amount of greenish-colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following nursing diagnoses is appropriate at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.
Pad the client's bed rails and headboard.
The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and headboard. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.
1 and 3
The nurse is caring for four women who are in labor. The nurse is aware that he or she will likely prepare which of the women for cesarean delivery? Select all that apply. 1. Fetus is in the left sacral posterior position. 2. Placenta is attached to the posterior portion of the uterine wall. 3. Fetus has been diagnosed with meningomyelocele. 4. Client is hepatitis B surface antigen positive. 5. The lecithin/sphingomyelin ratio in the amniotic fluid is 1.5:1.
Frequency every 3 minutes.
The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse's action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 130 seconds. 4. Attitude flexed.
Cord compression.
When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow.
Client will exhibit normal breathing function at discharge.
Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an amniotic fluid embolism during her labor? 1. Client will be infection free at discharge. 2. Client will exhibit normal breathing function at discharge. 3. Client will exhibit normal gastrointestinal function at discharge. 4. Client will void without pain at discharge.
Platelets 75,000.
Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.
2 and 3
Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.
Increasing fundal height measurements.
Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.
Shoulder dystocia.
Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.
Palpate bladder.
A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.
Confusion, drowsiness, and vomiting.
A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.
Check dilation and effacement.
A client has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 146, contractions every 5 minutes 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take? 1. Check dilation and effacement. 2. Prepare the client for surgery. 3. Place the bed in Trendelenburg position. 4. Check the biophysical profile results.
Fetal heart rate.
A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.
Hemorrhage.
An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.
Prolapsed cord.
Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 120 with variable decelerations. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta.
Meconium-stained fluid.
In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? 1. Placental abruption. 2. Meconium-stained fluid. 3. Polyhydramnios. 4. Late decelerations.
Epidurals do not fully sedate motor nerves.
The nurse is caring for two post-cesarean section clients in the postanesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia that the nurse should be aware of? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. Spinal clients complain of nausea and vomiting.
The woman is likely carrying a macrosomic fetus.
The nurse is monitoring a woman, G2 P1001, 41 weeks' gestation, in labor. A 12 p.m. assessment revealed: cervix, 4 cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced; -3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; -3 station; and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude? 1. Labor is progressing well. 2. The woman is likely carrying a macrosomic fetus. 3. The baby is in fetal distress. 4. The woman will be in second stage in about five hours.
The results are equivocal, warranting further sampling.
The results from a fetal blood sampling test are reported as pH 7.22. The nurse interprets the results as: 1. The baby is severely acidotic. 2. The baby must be delivered as soon as possible. 3. The results are equivocal, warranting further sampling. 4. The results are within normal limits.
Antacids.
To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which of the following medications? 1. Antacids. 2. Tranquilizers. 3. Antihypertensives. 4. Anticonvulsants.
Fetal distress.
A client, 42 weeks' gestation, is admitted to the labor and delivery suite with a diagnosis of acute oligohydramnios. The nurse must carefully observe this client for signs of which of the following? 1. Fetal distress. 2. Dehydration. 3. Oliguria. 4. Jaundice.
Fetal scalp sampling pH of 7.19.
A client is in active labor. Which of the following assessments would warrant immediate intervention? 1. Maternal PaCO2 of 40 mm Hg. 2. Alpha-fetoprotein values of 2 times normal. 3. 3 fetal heart accelerations during contractions. 4. Fetal scalp sampling pH of 7.19.
Maternal temperature.
A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate.
G5 P1211, cocaine abuser.
A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G2 P0010, 27 weeks' gestation. 2. G3 P1101, 17 years of age. 3. G4 P2101, cancer survivor. 4. G5 P1211, cocaine abuser.
1, 2, and 5
The nurse in the obstetrician's office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? Select all that apply. 1. 38-year-old in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation. 3. 30-year-old whose baby has a two-vessel cord. 4. 26-year-old with a history of long menstrual periods. 5. 22-year-old who smokes 2 packs of cigarettes every day.
A client with cardiac disease.
Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.
Previous cesarean section.
A woman is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. Station -2. 2. 38 weeks' gestation. 3. Reactive NST. 4. Previous cesarean section.
Endocervically.
A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes? 1. Intravenously. 2. Orally. 3. Endocervically. 4. Intrathecally.
Pink-tinged urine.
A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes +1. 4. Blood pressure 140/90.
Terbutaline (Brethine).
A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Betamethasone (Celestone). 4. Terbutaline (Brethine).
Begin oxytocin drip rate at 0.5 milliunits/min.
A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 milliunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.
