lippincott 312 exam 3
A mother expresses concern that picking up the infant whenever he cries will spoil him. What is the nurse's best response?
"Babies need comforting and cuddling; meeting these needs will not spoil him."
After the nurse explains about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed?
"I should try to push with each contraction."
A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the teaching when the client makes which statement?
"If left untreated, my baby might be born with an infection."
A pregnant client's partner coaches her with breathing and relaxation techniques as they were taught in birth preparation classes. When the client reaches 8-cm dilation, she screams out, "I can't do this anymore!" Which suggestion would be most helpful for the client's partner? "Let me take over the coaching for a while." "Ask your partner if she wants anesthesia." "Tell your partner that it will be over soon." "Maintain direct eye contact and breathe with her."
"Maintain direct eye contact and breathe with her."
A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood?
"The anesthetic may cause a severe headache, which is treatable."
A multigravida with a history of cesarean birth due to fetal distress is admitted for a trial labor and possible vaginal birth. After several hours of active labor, the primary care provider prescribes nalbuphine. The nurse evaluates the drug as effective when the client makes which statement?
"The contractions don't seem as painful as before."
During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions?
"True labor contractions are felt first in the lower back, then the abdomen."
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?"
A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first? -Initiate fetal and contraction monitoring. -Start the intravenous infusion. -Obtain the urine specimen. -Administer betamethasone.
-Initiate fetal and contraction monitoring.
A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. Walk in the hospital room. Use slow chest breathing. Request pain medication on a regular basis. Lightly massage the abdomen. Sip ice water.
-walk in the hospital room -use slow chest breathing. -lightly massage the abdomen
A nurse recognizes that labor is divided into how many stages?
3 we have talked about but really 4
A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply. interpretation of the fetal monitor strip analgesia or anesthesia being used prior birth history amount of vaginal bleeding or discharge support persons with the client
ALL
The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. What should the nurse do next?
Administer oxygen at 8 to 10 L by mask.
A multigravid client in active labor at term suddenly sits up and says, "I can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color. After calling for assistance, which action should the nurse take next?
Administer oxygen by face mask.
A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first?
Complete a vaginal examination.
A 34-year-old multigravida at 36 weeks' gestation is diagnosed with preterm labor. The client has experienced one infant death due to preterm birth at 28 weeks' gestation. On admission to the antenatal unit, the nurse determines that the fetal heart rate is 140 bpm. What should the nurse do next?
Continue monitoring the client and fetus.
A 30-year-old G3, T2, P0, A0, L2 is being monitored internally. She is being induced with IV oxytocin because she is postterm. The nurse notes the pattern below. The client is wedged to her side while lying in bed and is approximately 6 cm dilated and 100% effaced. What should the nurse do first?
Discontinue the oxytocin infusion.
A nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on this information, the nurse should include which nursing diagnosis in the client's care plan?
Fear related to a potentially difficult childbirth
After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action?
Hold the breath throughout the length of the contraction.
A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately?
Maintain a patent airway.
A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first?
Place gentle pressure upward on the fetal head.
The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priority intervention?
Prepare for an emergency cesarean birth.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?
Remain in a side-lying position with the head elevated.
A client treated with terbutaline for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? Report a heart rate greater than 120 beats/minute to the health care provider. Take terbutaline every 4 hours, during waking hours only. Call the health care provider if the fetus moves 10 times in an hour. Increase activity daily if not fatigued.
Report a heart rate greater than 120 beats/minute to the health care provider.
A nurse notices repetitive late decelerations on the fetal heart monitor. What is the best initial actions by the nurse?
Reposition the client, apply oxygen, and increase IV fluids.
Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?
The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.
Following an epidural and placement of internal monitors, a client's labor is augmented with oxytocin. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is >20 mm Hg with an abnormal fetal heart rate and pattern. Which action should the nurse take first?
Turn off the oxytocin infusion.
Which behavior should 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
The nurse is managing care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client?
anesthesia/pain level assessment every 30 minutes
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
client at 38 weeks' gestation with active herpes lesions
A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred?
complete uterine rupture
The nurse is caring for a multigravid client in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. What should the nurse do?
continue to monitor the pt and fetus
A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia?
excessive fetal activity and fetal tachycardia
A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important?
fetal heart rate
In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion?
fetal heart rate accelerations
When assessing the fetal heart rate tracing, a nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve:
fetal hypoxia
A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client?
left lateral
Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor?
loss of control
What assessment data of a laboring woman would require further intervention by the nurse? fetal heart rate (FHR) 150 beats/minute maternal heart rate 125 beats/minute temperature of 99.1° F (37.27° C) moderate contractions 3 minutes apart
maternal heart rate of 125 beats/minute
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem?
pain
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding?
passage of meconium by the fetus
Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately?
place client in trendelenburg position?? cover cord with sterile towels
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position?;
posterior
The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to
prevent seizures.
Which statement describes the term fetal position?
relationship of the fetus's presenting part to the mother's pelvis
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next?
temperature
A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the physician to order:
terbutaline
When assessing the fetal heart rate tracing, a nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if
the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.
Which fetal presentation is most favorable for birth?
vertex presentation
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client makes which statement?
"I can have an epidural as soon as I start contracting."
A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the nurse. After instruction about care while at home, which client statement indicates effective teaching? "It is permissible to douche if the fluid irritates my vaginal area." "I can take either a tub bath or a shower when I feel like it." "I should limit my fluid intake to less than 1 quart (0.95 L) daily." "I should contact the health care provider if my temperature is 100.4°F (38°C) or higher."
"I should contact the health care provider if my temperature is 100.4°F (38°C) or higher."
A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client?
Assess maternal contraction and fetal heart rate pattern.
The primary care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding?
Contractions cease.
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.
A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
Document fetal well-being.
What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?
beginning of one contraction to the beginning of the next contraction
A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor?
cervical dilation and effacement
While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions?
duration, frequency, and intensit
An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?
encouraging them to ask questions
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction?
hypotension
A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an IV infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? carefully titrating the oxytocin based on the client's pattern of labor monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes instructing the client to ambulate as tolerated helping the client use breathing exercises to manage her contractions
instructing the client to ambulate tolerate
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
latent phase
While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first? Perform a vaginal examination to determine dilation. Auscultate the client's blood pressure. Note the color, amount, and odor of the amniotic fluid. Prepare the client for imminent birth.
note the amount, color, and odor of the amniotic fluid.
A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:
promote fetal lung maturaity
A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?
promoting adequate hydration
Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client feels a strong need to have a bowel movement. What is the client most likely experiencing?
the second stage of labor
The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure?
umbilical cord
External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first?
Change the client's position.
For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?
Check the fetal heart rate.
A client is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client?
Continuous fetal heart rate monitoring will be implemented.
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding?
evidence of SROM
A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/minute. Which medication would the nurse expect the primary health care provider (HCP) to prescribe?
intravenous penicillin
The end of the third stage of labor is marked by what event?
delivery of the placenta
The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition?
prolapsed cord
A primary care provider has prescribed nalbuphine hydrochloride 10 mg intravenously for a client in active labor. The pharmacy supplies a vial labeled as 50 mg in a 5-mL vial. How many milliliters should the nurse administer? Record your answer using a whole number.
1 mL
A nurse needs to obtain a good monitor tracing on a client in labor. The client lies in a supine position. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which action should the nurse perform first?
Reposition the client to her left side. Immediately take the client's blood pressure and summon the health care provider (HCP). Start oxygen at 6 L via nasal cannula. Increase the IV fluids to correct the client's dehydration.
A full-term client is admitted for induction of labor. When admitted, her cervix is effaced 25% but has not dilated. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?
dinoprostone
A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time?
preparing for immediate delivery
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 recognize that the client is in which phase of labor?
transitional phase
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time?
walking around in the hallway
Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider?
A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps.
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?
cord lengthens outside the vagina
A client with active genital herpes is admitted to the labor and birth unit. During the first stage of labor. Which type of birth should the nurse anticipate for this client?
Cesarean
A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?
Stop the magnesium sulfate infusion.
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first?
the time of the membrane rupture
A primigravid client at 32 weeks' gestation with ruptured membranes is prescribed to receive betamethasone 12 mg intramuscularly for two doses 24 hours apart. When teaching the client about the medication, what should the nurse include as the purpose of this drug?
to accelerate fetal lung maturity
A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?
early decelerations
What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia?
offering encouragement and support
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug? The cervix will begin to dilate 2 cm/h. Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
contractions will occur every 2-3 min, lasting 40-60 seconds, mod. intensity, resting tone between contractions.
