maternity 2
Before giving a postpartum (PP) client the rubella vaccine, which of the following facts should the nurse include in client teaching?
The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects.
Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?
Urine retention
Labor can be indicated by which of the following?
The patient complains of back pain and the cervix is effacing and dilating.
The laboring patient is on continuous fetal monitoring when the nurse notes a decrease in the fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing intervention?
change position of patient
The nurse is assessing a women in active labor. She notes a small mass above the symphysis pubis, rounded and distended, non-tender. What intervention should the nurse take next?
check the last void
The nurse is assigned to a patient on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus?
1cm below the umbilicus
The nurse is concerned with the interactions between a mother and her 2-day-old infant. The nurse observes signs of impaired bonding and attachment. Which of the following should the nurse document as a cause for concern?
Calling the baby it or they
There are many medical reasons for induction of labor. A patient who develops an infection of the fetal membranes is at risk and is one indication for induction of labor. What is the appropriate term for infection of the fetal membranes?
Chorioamnionitis
At 37 weeks gestation a patient calls the labor and delivery floor and thinks she is in labor. What statement should the nurse recognize as an assessment finding for true labor?
Contraction, regular and lasting longer and stronger
Which woman are you most likely to have to prep for an episiotomy?
A multigravida with a history of heart problems; fetus is in vertex position
You are assisting with delivery of a primipara who has been induced and is now in hypertonic labor. The FHR drops suddenly. What must you be prepared to do?
Administer a tocolytic
The nurse should initially implement which intervention when a nulliparous woman telephones the hospital to report that she is in labor.
Ask the woman to describe why she believes that she is in labor
Betsy is recovering from a standard delivery. The nurse has just removed Betsy's epidural catheter and applied a sterile pressure dressing. What is it important for the nurse to do now?
Assess return of sensory and motor functions to the lower extremities
A 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 monitor, the initial nursing assessment is which of the following?
Assessing the baseline fetal heart rate
Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus?
B. Cervical laceration
A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred?
B. Forceps delivery
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have:
B. Increased efficiency of contractions
A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion?
Continuous electronic fetal monitoring
On which of the postpartum days can the client expect lochia serosa?
Days 3 to 10 PP
The nurse is assessing a breastfeeding mom 72 hours after delivery. When assessing her breast, the patient complains of bilateral breast pain around the entire breast. What is the most likely cause of the pain?
Engorgement
During the active phase of labor, the nurse should evaluate the labor pattern how often?
Every 30 minutes
A woman in latent labor for the past 12 hours is requesting medication to help her rest. What medication should the provider prescribe?
Secobarbital (Seconal)
A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis?
Semi-Fowler's.
The provider is admitting a patient to ripen her cervix for induction of labor. The order is for prostaglandin E2. The nurse is preparing to administer the medication via which route?
Vaginal
A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes.
stop infusion check b/p and HR perform vaginal exam administer o2 reposition client
Which of the following is the most frequent reason for postpartum hemorrhage?
uterine atony
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
Eight peripads per day.
Which of the following findings would be expected when assessing the postpartum client?
Fundus 1 cm above the umbilicus 1 hour postpartum.
Beverly is being admitted to labor and delivery. When admitting an obstetric patient in early labor, the first intervention by the nurse is:
Good rapport is established with the patient and significant other
Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the:
BLOOD PRESSURE!!!
Jane S. is a gravida 1, in the active phase of stage l labor. The fetal position is LOA. When Jane's membranes rupture, the nurse should expect to see:
Moderate amount of clear to straw-colored fluid
The initial descent of the fetus into the pelvis to zero station is which one of the cardinal movements of labor?
engagement
Which of the following signs signify that the second stage of labor has begun?
The urge to push occurs
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?
Variable decelerations
A woman's nurse-midwife tells the woman that she has developed dystocia. You would explain that this term means
Difficult or abnormal labor.
While caring for woman in labor the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:
Uteroplacental insufficiency
A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching?
"I need to stop breastfeeding until this condition resolves."
Susan is in labor with her second child. She knows that she will want epidural anesthesia and she has already signed her consent form. What must the nurse do before Susan receives the epidural?
Administer a fluid bolus through the IV line to reduce the risk of hypotension
The RN in labor and delivery documents the fetus as ROA. To what does this documentation refer for a fetus?
Fetal position
Given a prepartum hemoglobin value of 14 gm/dL and hematocrit of 42 percent, which postpartum measurements should you report to the RN?
Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean
The mechanical method most used for cervical ripening is which of the following?
Membrane stripping
As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be:
Soft, non-tender; colostrum is present.
After administration of epidural anesthesia during labor, the patient develops a temperature of 100.1F. The patient's husband is asking if she is "getting sick". How should the nurse respond to the patient and her husband?
"This elevation in temperature is a possible side effect of the anesthesia. We will notify the provider and assess temperature again in an hour."
While in labor a woman with a prior history of cesarean birth complains of light-headedness and dizziness. The nurse assesses the patient and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?
uterine rupture
Opiods are often used in labor for pharmacologic pain management. A patient in the transition phase of labor is requesting fentanyl (Sublimaze) for pain. How should the nurse respond to her request?
"Pain medication given now might cause the baby to have slow respirations and is not recommended, lets try to focus and breathe."
The nurse instructs the client about skin massage and the gate control theory of pain. Which of the following statements would be appropriate for the nurse to include for patient understanding of the nonpharmacological pain relief methods?
A technique to prevent the painful stimuli from entering the brain
Which woman should you suspect of having endometritis?
A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative.
The expected fetal heart rate response in an active fetus is which of the following:
Acceleration of at least 15 bpm for 15 seconds
A nurse is caring for a postpartum (PP) client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?
Activated partial thromboplastin time
A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?
Active phase
A woman presents to the delivery suite at 36 weeks' gestation reporting continuous, heavy vaginal discharge and pelvic pressure. A Nitrazine test confirms PROM. There is no sign of infection. She is admitted to the hospital for watchful waiting. You will be caring for her; which of the following interventions will you be most likely to perform?
Administer 48 hours of antibiotics IV followed by 5 days PO.
Marianne has been in labor for many hours and is becoming exhausted. Her fetus is showing increasing signs of distress, and the physician orders a cesarean delivery. Marianne and her partner had their hearts set on natural childbirth. Although they attended childbirth classes, they focused on vaginal methods and are now distressed and unsure what to expect. What is the most important nursing intervention that you can provide at this point?
Briefly describe what they will experience during the procedure, explain each procedure as you perform it, and encourage Marianne's partner to participate whenever possible
Erin, a 19-year-old first-time mother in the second stage of labor who has been given an epidural, reports severe, unrelenting abdominal pain and rates it as 10 on a scale of 0 to 10. As the nurse, what should you do?
Call the obstetrician; severe unrelenting abdominal pain could indicate placental abruption, uterine rupture, or other undiagnosed complication.
A woman at 32 weeks' gestation is admitted in preterm labor. On your admission assessment, which of following findings should cause the nurse to question the administration of a tocolytic agent?
Cervical dilation of 5 cm.
A woman requires treatment to ripen her cervix, and you are discussing prostaglandin options with her. She has heard that an oral drug is available. You suggest that she ask her doctor about which of the following?
Cervidil
When examining the fetal monitor strip after the rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:
Change the client's position
A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
Changes in the shape of the uterus
Within 24 hours of delivery, Diane begins to complain of pain in the pelvic region. Comfort measures and medication fail to eliminate the pain, her pulse is rapid, and her blood pressure, hematocrit, and hemoglobin are low. Her fundus is firm, however, and her lochia is dark red and flowing in only moderate amounts; no pooling is evident. You tell the RN you suspect
Deep pelvic hematoma
A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this?
Dorsiflex her right foot and ask if she has pain in her calf.
The client is 35 weeks of gestation and is being admitted for vaginal bleeding. The patient is stable at the time of admission. The priority nursing assessment for the client is for:
Fetal heart tones.
Twelve hours after delivery, the fundus of a woman who has just delivered her fifth child after 14 hours of labor is two fingers above the umbilicus and her uterus feels soft and spongy. What should you do first?
Gently massage the fundus until it tones up
Cheryl plans to deliver by cesarean section. On the day of the procedure, she and her partner arrive and pre-register. What is the most important part of her preparation for surgery?
Having blood drawn
During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent and the baseline FHR is within normal limits. What should you do first?
Help the woman change positions
At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what do you prepare her?
Hospitalization, tocolytic therapy, and IM corticosteroids
If a fetus is in an ROA position during labor, you would interpret this to mean the fetus is
In a longitudinal lie facing the left posterior
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is:
Indicates the presence of infection.
A woman in labor at the hospital has just received an epidural block. Which intervention is priority before and during epidural placement?
Provide adequate IV fluids to maintain her blood pressure
A postpartum patient 2 hours after delivery via cesarean birth is complaining of shortness of breath and sudden onset of pain. What is the primary nursing intervention for this patient?
Raise HOB
When planning care for a postpartum patient, the nurse is aware the most common site for post partum infection is which of the following?
Reproductive
A multigravida presents at 31 weeks' gestation with signs and symptoms of preterm labor. The diagnosis is confirmed and she is admitted and given magnesium sulfate. What must you report as part of her care?
Respiratory depression, hypotension, absent tendon reflexes
A woman with cardiac disease delivered a seven pound baby by C-Section. Which of the following interventions should be implemented during the immediate postpartum period?
Rest, stool softeners, and monitoring tolerance of activity.
Charting on the nursing care plan patient care, which nursing diagnosis has the highest priority for a postpartum patient?
Risk for injury: postpartum hemorrhage related to uterine atony
A nonsmoking woman, pregnant for the first time at 28 years of age and expecting twins, presents at 36 weeks' gestation complaining of backache and painful uterine contractions. You examine her and find no cervical dilation or pooling of fluid. What is the best course of action?
Send her home for bed rest and hydration with orders to return if her water breaks or her contractions worsen.
The practice of performing routine episiotomies has decreased in the past several years. Although the practice has decreased, which of the following is an indication of a need for an episiotomy?
Shoulder dystocia
You are caring for a woman who is receiving IV antibiotics and supportive care for endometritis. Which of the following findings should you report as soon as you notice it?
Steadily decreasing volume of urine
A woman, 41 weeks gestation, is admitted for induction of labor with IV Pitocin. The fetal monitor strip is noted to have contractions every 2 minutes lasting 60-90 seconds. What is the highest priority intervention for the nurse?
Stop the IV Pitocin infusion
A patient was started on induction of labor at 0500am. It is now 1200noon and she is only dilated to 4cm. Her contractions are every 1 minutes and the fetus is showing signs of distress. What is the priority intervention by the nurse?
Stop the oxytocin infusion
Jane and her husband have attended childbirth preparation classes and they feel very hopeful and optimistic about having a natural childbirth. As Jane progresses to 8cm dilation, she can no longer endure the pain at the peak of each contraction and she begs the nurse for an epidural. How can the nurse best help Jane?
Support Jane's decision and call the obstetrician to discuss the epidural with Jane
A woman presents in advanced labor, and birth appears imminent. What is the most important and appropriate aspect of admission for this woman?
Taking her blood pressure and determining whether clonus or edema is present
On the first postpartum (PP) night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases?
Taking-in phase
While educating a class of postpartum patients before discharge home after delivery, one woman asks when "will I stop bleeding?" How should the nurse respond?
The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks
The laboring patient who is at 3cm dilation and 25 percent effaced is asking for analgesia. The nurse explains the analgesia is usually not administered prior to the establishment of the active phase. Identify the appropriate rationale for this practice.
This may prolong labor and increase complications
Brenda develops mastitis 3 weeks after delivery. What part of self-care do you tell her is most important?
To breast-feed or otherwise empty her breasts every 1 to 2 hours
The laboring patient is having contractions every 2-3 minutes, lasting 45-60 seconds and of strong intensity. The fetal head crowns when the client pushes. The cervix is completely dilated (10 centimeters) and 100 percent effaced. The nurse assesses the patient to be in what stage or phase of labor?
Transition
A woman arrives at labor and delivery with contractions every 2-3 minutes lasting 30-45 seconds reporting that she "thinks my water broke". On exam, the RN notes the presenting part is difficult to determine. What intervention should the LPN anticipate?
Use of an ultrasound to determine position
Which of the following fetal positions is most favorable for birth
Vertex
After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed:
Below the umbilicus on the right side
A woman is documented on the labor and delivery board to be 7cm dilated. Her family wants to know how long she will be in labor. The nurse should provide which information to the family?
"She is in active labor, she is progressing at this point and we will keep you posted."
A patient, 38 weeks gestation, pregnant with her first child calls the clinic and states "my baby is lower and it is more difficult to walk" and ask if she should come to the hospital to be checked. How should the nurse respond?
"The baby has dropped into the pelvis, this is called lightening, your body and baby are getting ready for labor in the next few weeks."
During labor, a woman at 41 weeks gestation notes her amniotic fluid is leaking and is green in color. She is asking the nurse why the fluid is green. What is an appropriate response by the nurse?
"This is meconium-stained fluid from the baby."
What is the normally accepted fetal heart rate range?
110-160
A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
3 days PP
Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse?
Absent verbalization about the birthing process.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initialnursing action in performing this assessment is which of the following?
C. Ask the mother to urinate and empty her bladder.
A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority?
C. Monitoring fetal heart rate.
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive assessment that uterine contractions are effective would be:
Dilatation of cervix
When documenting the fetus is at "zero station", the nurse knows this is where in relation to the pelvic structure?
Pelvic Crest
A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period, the nurse plans to take the woman's vital signs:
Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
You assess that the fetus of a woman is in an occiput posterior position. Which of the following identifies the way you would expect her labor to differ from others?
Experience of additional back pain.
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?
FHR 90 BPM
A woman at 28 weeks' gestation is being assessed to determine if she is experiencing pre-term labor. Which of the following findings indicates that pre-term labor is occurring?
Fetal fibrinectin is present in vaginal secretions.
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be:
Hypotension
The process by which the reproductive organs return to the nonpregnant size and function is termed what?
Involution
The nurse assesses the patient who is one hour postpartum and observes a heavy steady gush of bright red blood from the vagina in the presence of a firm fundus. Select the most likely cause of the signs and symptoms.
Lacerations.
At the hospital, a client is attached to the fetal monitor for uterine rupture. The nurse would assess for which pattern indicating change in the uterus impacting the fetus?
Late decelerations.
The nurse is working with a patient in labor. She is happy and cheerful, and states she is "ready to see her baby." What stage or phase of labor would she anticipate the patient to be in right now?
Latent phase
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
Left lower quadrant
A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is:
Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus.
Which type of lochia should the nurse expect to find in a client 2 days PP?
Lochia rubra
The following are nursing measures commonly offered to women in labor. Which nursing intervention would probably be most effective in applying the gate control theory for relief of labor pain?
Massage for the woman's back
The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:
Massage the fungus
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis?
Mastitis
A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working, she:
May lose the ability to push
Which lochia pattern should you report immediately to the RN or primary practitioner?
Moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond?
Perform a pelvic examination
A nurse is assessing a client in the 4th stage of labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following?
Notify the physician
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
Notify the physician.
When a labor patient has either forceps or vacuum-assisted types of delivery, what type of delivery is this noted?
Operative vaginal delivery
When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour?
Pad count
Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum?
Pain in left calf with dorsiflexion of the left foot
The patient is 5 cm dilated, 80 percent effaced, and 0 station. Her contractions are increasing to every 2-3 minutes, lasting 50 seconds. The client is increasingly uncomfortable. She is apprehensive but appropriate and focused on her breathing and relaxation. Select the most appropriate nursing diagnosis for the client.
Pain related to increasing frequency and intensity of contractions
A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to
Palpate her fundus.
The four essential components of labor are known as the "four P's". Which of the four P's involves the pelvis?
Passageway
Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors?
Passageway, contractions, placental position, and function, psychological response.
Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history?
Peripheral vascular disease
During a postpartum exam on the day of delivery, the woman complains that she is still so sore that she can't sit comfortably. You examine her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point?
Place an ice pack
When a woman in labor has reached 8 cm dilation, you notice the fetal heat rate suddenly slows. On perineal inspection, you observe the fetal cord has prolapsed. Your first action would be to
Place her in a knee-chest position.
A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should:
Support the perineum with the hand to prevent tearing and tell the client to pant.
Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:
Uses the peri bottle to rinse upward into her vagina.
A client is admitted to the L & D suite at 36 weeks' gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?
Uterine rupture
Which of the following complications is most likely responsible for a delayed postpartum hemorrhage?
Uterine subinvolution
Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her?
Wound care and hand washing
Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts?
\Teaching how to express her breasts in a warm shower
The LPN is assisting in a vaginal exam of a woman with clear vaginal fluid leaking at 37 weeks gestation. The RN is using a speculum and performs a nitrazine paper test for rule out rupture of membranes. If the test is positive, what color will the nitrazine turn?
blue
When completing a routine admission on the labor and delivery unit for induction of labor, after the admission information is collected, what is the next priority in planning care for the patient?
fetal assessment
A multigravida is admitted to the hospital in active labor. The client's and the fetus' condition have been good since admission. The client calls out to the nurse, "the baby is coming!" What is the first action of the nurse?
inspect the perineum
When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:
An acceleration
On assessment of a 2-day postpartum patient the nurses finds the fundus is boggy, at U and slightly to the right. What is the most likely cause of this assessment finding?
Bladder distention
You are preparing an injection of a narcotic to relieve a pregnant woman's pain. As you are about to give it, she asks you for a bedpan because she has to move her bowels. Your best action would be to
Hold the injection until you evaluate her labor progress
Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first?
Place one hand over the symphysis pubis.
Nancy has presented in the early phase of labor. She's experiencing abdominal pain and shows signs of growing anxiety about the pain. What is the best pain management technique the nurse can suggest at this stage?
Practicing effleurage on the abdomen
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client?
Prepare an ice pack for application to the area.
A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. You are alone with her and notice that the umbilical cord is hanging out of the vagina. What should you do next?
Put her in bed immediately, call for help, and hold the presenting part of the cord.
Which of the following findings meets the criteria of a reassuring FHR pattern?
Variability averages between 6 - 10 BPM.
You are readying a new mother for discharge. You note that she is not rubella-immune, so you administer rubella vaccine. She will breast-feed her infant and plans to get pregnant again as soon as possible. What is the most important information you should give her about this immunization?
Warn her not to attempt another pregnancy for at least 3 months
When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?
Weak and rapid pulse
A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Which of the following instructions would be included on the list. Select all that apply.
Wear a supportive bra. Rest during the acute phase. Continue to breastfeed if the breasts are not too sore.
