NUR410 MATERNITY

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care?

A woman may spend time thinking about what is happening to her.

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

Dilation of cervix

In providing culturally competent care to a laboring woman, which is a priority?

Identify how the client expresses labor pain

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

Palpate the mother's radial pulse at the same time.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?

The client's cervix is fully dilated.

The nurse is caring for a client at 39 weeks' gestation and whose fetal station is noted as a 0 (zero). The nurse is correct to document which?

The fetus is in the true pelvis and engaged.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

Turn her or ask her to turn to her side.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply.

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

A client in labor receiving epidural anesthesia develops hypotension. Which of the following would the nurse do first?

Give an intravenous bolus of fluid

The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time?

reposition the client on either side

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?

Provide care under the supervision of an RN

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs.

A woman entering her third trimester of pregnancy asks the nurse how much weight she should gain during this trimester. What is the nurse's best answer?

1 lb/week

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor?

"She is in active labor; she is progressing at this point and we will keep you posted."

When collecting data to devise a labor plan for a multiparous woman, which question bestallows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries."

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?

"The injection is given in the space outside the spinal cord."

A woman, who has been in labor for a few hours, is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat?

"You could have some hard candy to suck on."

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess amount of cervical dilation.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

Assess fetal heart rate for fetal safety.

During which time is the nurse correct to document the end of the third stage of labor?

At the time of placental delivery

When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage?

Cervical dilation

The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the mainsource of pain during the first stage?

Cervix

The nurse is caring for a laboring client whose fetus has slowed in the descent down the birth canal. The health care provider is checking on the client. Which nursing action is anticipated?

Complete a urinary catheterization

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?

Complete cervical dilation and time of fetal birth

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?

Continuous labor support

A gravida 3 para 2 client has been in labor for 4 hours and is experiencing severe back pain with each contraction. She is extremely uncomfortable and distressed because she never had this type of pain with her other labors. Which intervention can the nurse point out is best for this client to try to address her pain?

Effleurage

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

Engagement

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6 to 25 beats per minute.

During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing should the nurse assess on the monitor to confirm this finding?

Fetal heart rate declining late with contractions and remaining depressed

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?

Inability to push

A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.

When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture?

Meconium-stained amniotic fluid

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritizeat this stage?

Practicing effleurage on the abdomen

A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize?

Quickly evaluate the perineum.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.

The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?

Use a birthing ball and find a position of comfort.

Which assessment findings of the fetus during labor are reassuring? Select all that apply.

Variability between 18-20 bpm Fetal heart baseline of 130 bpm

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as:

a possible infection.

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

acupressure

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask

When teaching a group of soon-to-be parents about the structures of the fetal skull, the nurse describes the anterior fontanel (fontanelle). Which description would the nurse include?

approximately 2 to 3 cm in size

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

cervical dilation (dilatation)

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?

every 15 minutes

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

external electronic fetal monitoring

A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. For which condition associated with shoulder presentation during a vaginal birth should the nurse assess?

fetal anomalies

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed

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?

frank

The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as:

frequency.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

lie

A nurse is providing care to a woman in labor. After asssessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use?

longitudinal

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

meperidine

A pregnant woman at 37 weeks gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are:

occurring about every 5 minutes.

A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply.

presence of a support partner low anxiety level participation in a pregnancy exercise program

Which should the nurse identify as a risk associated with anemia during pregnancy?

preterm birth

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?

restoration of blood flow to uterus and placenta

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?

sudden gush of dark blood from the vagina

The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?

Take no extra measures; prepare for a standard labor.

A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?

Reassuring; it is associated with normal acid-base balance.

Which statement is true regarding analgesia versus anesthesia?

Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn.

A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucous discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse?

"A one time discharge of bloody mucus in the toilet might have been your mucous plug."

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

"It distracts your brain from the sensations of pain."

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

The nurse is caring for a primipara with PROM who appears extremely anxious and reveals that she is scared her birthing process will be extremely painful because it will be "dry". Which is the best response from the nurse?

"No birth is ever really dry, because amniotic fluid continues to be manufactured."

A nurse is performing an assessment on a client in early labor who is discouraged about the seemingly slow progress of her labor. Which response should the nurse prioritize for this client after noting the effacement is progressing even though the cervix is still only 2 cm for the past 2 hours?

"You are still 2 cm dilated, but the cervix is thinning out nicely."

What changes does the cervix undergo in preparation for childbirth? Select all that apply.

It produces mucus to lubricate the vaginal canal. It protects the uterus from infection. It opens up to allow passage of the infant.

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?

Long axis of fetus is perpendicular to that of client.

A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis. When developing this client's plan of care, which intervention would the nurse include?

implementing measures for a vaginal birth