OB ch. 14
C
The nurse is assisting a health care provider in inserting an epidural into a laboring mother. Completion of which nursing task helps prevent maternal hypotension? a. Working with the mother on pattern breathing b. Elevating the client's legs while in bed c. Priming tubing for initiating a fluid bolus d. Administrating a vasopressor
A
A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? a. Determine if the client is in true or false labor. b. Ask if this is the client's first pregnancy. c. Notify the healthcare provider. d. Assess to see if the client has any drug allergies.
B
A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: a. "Effleurage is the pattern for cleaning the perineum before birth." b. "Effleurage is light abdominal massage used to displace pain." c. "Effleurage is the effect of a full bladder on fetal descent." d. "Effleurage is massaging the perineum as the fetal enlarges the vaginal opening."
D
A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension? a. betamethasone b. methylergonovine c. atropine d. ephedrine
D
Which action is a priority when caring for a woman during the fourth stage of labor? a. offering fluids as indicated b. encouraging the woman to void c. assisting with perineal care d. assessing the uterine fundus
A
The nurse in an obstetric clinic is conducting client education with a group of expectant mothers. One young woman asks the nurse to tell the group what labor pain is like. What would be the nurse's best response? a. "The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in." b. "It has been described as the worst pain you will ever feel." c. "It comes in waves." d. "It is best evaluated by talking with visitors in the labor room because they know you best."
C
A client asks why she should learn breathing patterns for labor. After instruction is given, the nurse determines teaching has been effective when the client states: a. "Breathing patterns must be used with a coach." b. "Breathing patterns cannot be taught while in labor." c. "Breathing patterns are distraction techniques taught to decrease pain in labor." d. "Breathing patterns help a woman concentrate on pain."
A
A client has just received combined spinal epidural. Which nursing assessment should be performed first? a. Assess vital signs. b. Assess pain level using a pain scale. c. Assess for progress in labor. d. Assess for spontaneous rupture of membranes. e. Assess for fetal tachycardia.
A
A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? a. Check the fetal heart rate. b. Perform a vaginal exam. c. Notify the primary care provider immediately. d. Change the linen saver pad.
A
A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? a. respiratory depression b. urinary retention c. abdominal distention d. hyperreflexia
C
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: a. +2 station. b. 0 station. c. -2 station. d. crowning.
C
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? a. every 5 minutes b. every 10 minutes c. every 15 minutes d. every 20 minutes
D
Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority? a. Temperature b. Pain level c. Respiratory rate d. Blood pressure
A, B, C
The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. a. determining the presentation of the fetus b. determining the position of the fetus c. determining the lie of the fetus d. determining the weight of the fetus e. determining the size of the fetus
C
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? a. Risk factors b. Maternal status c. Fetal status d. Maternal obstetrical history
A
A maternity nurse is aware that the fetal head is the presenting part in complete extension position. Which type of birth should the maternity nurse anticipate? a. prolonged labor and possible cesarean birth b. precipitous labor and birth c. a normal labor and a spontaneous vaginal birth d. a forceps-assisted vaginal birth
B
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? a. Ask the woman to hold her breath while assessing the FHR. b. Palpate the mother's radial pulse at the same time. c. Have the woman lie completely flat on her back while auscultating. d. Instruct the woman to bend her knees and flex her hips.
C
A nurse is evaluating the external fetal monitor tracing shown. Which nursing intervention would follow? a. Turn client to the left side. b. Administer oxygen. c. Offer comfort measures. d. Notify the health care provider.
C
A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using? a. Massage b. Abdominal imagery c. Effleurage d. Pain pathway blockage
A
Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH? a. 7.2 b. 7.0 c. 6.8 d. 7.4
D
The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize? a. late decelerations b. early decelerations c. increased variability d. decreased variability
C
The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? a. 90 to 140 bpm b. 100 to 150 bpm c. 110 to 160 bpm d. 120 to 170 bpm
C
The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer? a. On the right side of the abdomen b. At the level of the umbilicus c. On the uterine fundus d. Midline but low on the abdomen
B
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? a. Engagement of fetus b. Dilation of cervix c. Rupture of amniotic membranes d. Bloody show
B
The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse prioritize in this situation? a. Perform a vaginal exam to assess cervical dilation and effacement. b. Continue to monitor the FHR because this pattern is benign. c. Stay with the client while reporting the finding to the primary care provider. d. Administer oxygen after turning the client on her left side.
D
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: a. right upper quadrant. b. right lower quadrant. c. left upper quadrant. d. left lower quadrant.
A
To assess the frequency of a woman's labor contractions, the nurse would time: a. the beginning of one contraction to the beginning of the next. b. the end of one contraction to the beginning of the next. c. the interval between the acme of two consecutive contractions. d. how many contractions occur in 5 minutes.
A, C
Which assessment findings of the fetus during labor are reassuring? Select all that apply. a. Variability between 18-20 bpm b. Late decelerations c. Fetal heart baseline of 130 bpm d. Repeated variable decelerations e. Gradual increase in the fetal heart rate baseline
D
Which medication is administered to reverse the depressant effects of opioids? a. meperidine b. butorphanol c. nalbuphine d. naloxone
A
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? a. FHR fluctuates from 6 to 25 beats per minute. b. FHR fluctuation range is undetectable. c. FHR fluctuates less than 5 beats per minute. d. FHR fluctuates over 25 beats per minute.