Module 4 PrepU ?s

The nurse is teaching a primigravida who does not speak the dominant language. The nurse will teach about the most common type of fetal presentation. Which presentation will the nurse prepare? occiput presentation using a PowerPoint presentation breech presentation using a picture cephalic presentation using preprinted materials in the client's language footling presentation drawing a hand-prepared diagram

cephalic presentation using preprinted materials in the client's language

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? engagement expulsion extension flexion

engagement

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? complete full frank footling

frank

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? 0 +2 -2 +4

-2

A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action? Bathroom privileges Ambulation ad lib Up in chair TID Complete bed rest

Ambulation ad lib

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? Greenish fluid Bloody fluid Cloudy white fluid Clear to straw-colored fluid

Clear to straw-colored fluid

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings? The client is in active labor. The duration of the contractions is every 5 minutes. The frequency of the contractions is every 5 minutes. The client can be sent home.

The frequency of the contractions is every 5 minutes.

The nurse is caring for a client who is a primigravida. Which statement is best to improve the client's psyche? "You will be finished soon." "You will be pushing very soon." "Your second pregnancy will be easier." "You are doing a great job"

"You are doing a great job"

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? Fetal lie Fetal position Fetal presentation Fetal attitude

Fetal lie

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? Fetal position Fetal attitude Fetal station Fetal size

Fetal position

Which complication occurs as a result of ineffective breathing patterns? hiccups hyperventilation nausea flatus

hyperventilation

Assessment of a pregnant client reveals that she is experiencing Braxton Hicks contractions. Which finding would support this assessment? irregular pattern increasing duration typically very strong cervical dilation (dilatation) occurring

irregular pattern

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? brow shoulders occiput buttocks

occiput

A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate? "Call us back when you start having contractions." "Come to the clinic or emergency department for an evaluation." "Come in as soon as you feel the urge to push." "Drink 3 to 4 glasses of water and lie down."

"Come to the clinic or emergency department for an evaluation."

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is elongated, the width is roomy, but the length is narrow." "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is flat and narrow, making it extremely difficult for the neonate to pass through." "It is rounded in shape and allows ample room for the neonate to fit through the passageway."

"It is rounded in shape and allows ample room for the neonate to fit through the passageway."

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? "My contractions are about 6 minutes apart and regular." "The contractions slow down when I walk around." "If I try to talk to my partner during a contraction, I can't." "I'm feeling contractions mostly in my back."

"The contractions slow down when I walk around."

Dilation (dilatation) follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement? 12 to 14 cm 3 to 4 cm 7 to 8 cm 8 to 10 cm

8 to 10 cm

During which time is the nurse correct to document the end of the third stage of labor? When the mother is moved to the postpartum unit When pushing begins At the time of placental delivery Following fetal birth

At the time of placental delivery

A nurse is assessing a female client in the labor admission unit. The client has been having contractions every 5 minutes for the past 6 hours. Which finding would the nurse use to determine if the client is experiencing true labor? The client's cervix has changes of effacement and dilation (dilatation). The client has a history of giving birth to two infants. The client reports the contractions stay in the abdomen. Walking helps the reduce the frequency of the client's contractions.

The client's cervix has changes of effacement and dilation (dilatation).

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? The client has contractions once every two minutes. The infant is born. The client's cervix is fully dilated. The client experiences her first full contraction

The client's cervix is fully dilated.

The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth? forceps-assisted vacuum extraction cesarean vaginal

cesarean

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? extent of opening to its widest diameter degree of thinning passage of the mucous plug fetal presenting part

degree of thinning

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? peak frequency duration intensity

duration

A group of nursing students are preparing a presentation that will illustrate various components of the birthing process. When discussing the pelvis, the students should point out that the pelvis is often referred to as which term? passenger powers passageway psyche

passageway

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor? decrease in duration of contractions rupture of amniotic membranes development of a membrane further closing the cervix decrease in vaginal secretions

rupture of amniotic membranes

Which description is best when documenting an accurate client contraction? The client's contractions last 30 seconds with rest between. The client's contractions are 5 minutes apart and last 45 seconds. The client cries with each contraction and holds the support partner's hand. The client states the contraction as an 8 on the pain scale.

The client's contractions are 5 minutes apart and last 45 seconds.

A nulliparous client at 37 weeks' gestation calls the labor and delivery unit stating she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions? bloody mucus in the toilet once earlier in the day scant amount of thick, white vaginal discharge, no odor contraction, regular and lasting longer and stronger contractions, irregular, lasting 15 to 20 seconds

contraction, regular and lasting longer and stronger