OB exam 3 8-11

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A nurse is caring for a full-term pregnant client undergoing an induction with oxytocin. Upon assessment, the nurse determines that the fetus is in distress and identifies a Category III fetal heart rate pattern. The nurse will complete interventions in which order? Discontinue oxytocin. 1 Notify the provider. 3 Change maternal position to left lateral position. 2 Assess emotional response and provide reassurance. 4

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The nurse is caring for a term gestation client in active labor when her membranes rupture spontaneously. Prioritize the following nursing interventions. A: Document the assessment findings along with time of rupture. 3 B: Assess the color, odor, and amount of fluid. 2 C: Assess the fetal heart rate. 1 D: Update the physician on spontaneous rupture of membranes and labor progress.4

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A client who had a cesarean section calls to the nurses' station and requests the nurse to come to the room two hours after the foley catheter was removed. The client asks the nurse to check for increased vaginal bleeding, due to a feeling of a gush of blood. The nurse notes a large amount of blood, and upon palpation notes that the uterus is displaced to the right and the fundus is boggy. What is the priority intervention the nurse will provide to the client? A: Retrieve bedpan to allow for client to attempt to empty bladder B: Administer oxytocin intramuscularly per order C: Massage the uterus until a return to a midline position and firm D: Administer a bolus of IV fluids due to the increased bleeding

A gravid patient presents to labor and delivery for labor induction due to preeclampsia. The nurse notes the Bishop score of 5 in her medical record. Which intervention would the nurse anticipate? A: Cervical ripening agents B: Amniotomy C: Oxytocin infusion D: Cesarean delivery

A nurse is monitoring a patient who is 26 weeks gestation and in preterm labor. Which assessment data does the nurse document as a normal finding? A: Minimal variability B: FHR 168 C: Late decelerations D: Contractions every 3 to 4 minutes

A nurse is providing emotional support to a patient who just experienced a stillbirth at 38 weeks' gestation. Which statement would indicate a non-therapeutic response by the nurse when providing support to the patient? A: "I am sorry for your loss, but don't worry, you still have time to become pregnant again." B: "I am going to hang this image of a butterfly outside your door to maintain your privacy and comfort." C: "I am going to provide your family when mementos to take home with you, such as photos of the baby." D: "I am here to support you. Let's discuss any religious or cultural needs you may have."

A nurse is teaching a childbirth education class for expectant parents. One of the clients is concerned about cesarean sections and asks what the most common indication for needing a cesarean section would be. What is the appropriate nursing response? A: Arrest of labor B: Malpresentation C: Multiple gestation D: Preeclampsia

A nurse on the postpartum care unit is anticipating admission of a client immediately after an emergency cesarean section. The surgery was due to a Category III fetal monitor tracing and was performed under general anesthesia. What client concerns does the nurse anticipate as addressing with this client? A: The need for the C-section delivery B: The frequency of vital signs C: The need to bottle feed the infant D: The type of delivery for future pregnancies

A primiparous woman in active labor is having uterine contractions that are weak and becoming less frequent. She has not made any cervical change in 1 hour. Which is the best nursing action? A: Assist the patient with ambulation or position changes. B: Prepare the patient for a cesarean delivery. C: Administer tocolytic medications. D: Warn the woman of the second stage disorder and risks of cesarean delivery.

An amniotomy was just performed on a laboring patient. Which nursing action has highest priority following an amniotomy? A: Assess fetal heart rate. B: Assess maternal temperature. C: Change the pad under the patient's buttocks. D: Assess for odor of the amniotic fluid.

Cardiopulmonary resuscitation (CPR) is being performed on a gravid patient with suspected amniotic fluid embolism. The nurse knows that certain adjustments should be made during CPR on a pregnant woman. Which adjustment is recommended? A: Displacement of the uterus to the left side B: Hand placement for chest compressions slightly lower C: Chest compressions performed at a faster rate D: Bag-mask-valve ventilation instead of intubation

Following a cesarean section delivery of a full term healthy female infant, the nurse is explaining to the client that another Rhogam injection will not be required. What explanation would the nurse offer to support this information? A: "The infant is Rh negative, so another dose is not required." B: "You received the scheduled dose at 28 weeks, so do not need one after delivery." C: "You do not need another dose since you had a tubal sterilization during your surgery." D: "Rhogam is not required for c-section deliveries."

Following completion of four deliveries via cesarean section, the nurse states in shift report the APGAR scores for the four newborns. Which infant does the oncoming nurse see first? A: APGAR 5, APGAR 7 B: APGAR 8, APGAR 8 C: APGAR 9, APGAR 10 D: APGAR 7, APGAR 9

Following the delivery of a term newborn, the mother experiences a moderate urge to push and a gush of blood emerges from the vagina. The nurse recognizes this as: A: Indicating the placenta is about to deliver B: The formation of a vaginal hematoma C: Perform a cervical exam D: Signs of a postpartum hemorrhage

The labor nurse is performing a vaginal exam on a patient whose membranes just ruptured spontaneously. The nurse feels a loop of umbilical cord in the vagina. Which nursing action has the highest priority? A: Lift the presenting part off the umbilical cord. B: Administer oxygen via face mask. C: Discontinue oxytocin infusion. D: Give an IV fluid bolus of 300 cc.

The nurse initiates a fluid bolus prior to epidural administration. which is the purpose of this action? A: To stabilize post-epidural blood pressure B: To prevent hypovolemia following blood loss after delivery C: To increase amniotic fluid volume and cushion the umbilical cord D: To flush fentanyl metabolites from maternal circulation

The nurse is caring for a client in the first stage labor. To assist the progression of labor, the nurse recommends: A: Changing positions and sitting upright B: Maintaining a side-lying position only C: Receiving an epidural as early as possible so she can relax and rest D: Limiting visitors at the beside to promote rest

The nurse is caring for a family with an intrauterine fetal demise. Which statement by the nurse is most helpful for grieving families? A: "I am here if you want to talk about the baby." B: "You can try to get pregnant again in 6 weeks." C: "At least you did not get too attached to this baby." D: "We will give you a lot of pain medication, so you don't feel anything."

The nurse is caring for a laboring client who is waiting for the anesthesiologist to come administer the epidural. Which does the nurse anticipate that the obstetrician will order for this client to prevent a common adverse reaction following the epidural placement? A: IV fluid bolus B: Left-tilt position C: Check vitals every 5 minutes D: Assist client to bathroom

The nurse is caring for a patient when the provider decides to perform an amniotomy. Which is initial nursing action performed by the nurse during an amniotomy? A: Assess the fetal heart rate. B: Document the color of amniotic fluid. C: Perform a sterile vaginal exam. D: Provide pericare.

The nurse is caring for a patient who has experienced a prolonged labor and difficulty pushing. The FHR is 90 bpm and the nurse is aware that which nursing action is contraindicated at this time? A: Closed glottis pushing B: Confirming FHR versus maternal heart rate C: Performing a vaginal exam and assessing for a prolapsed cord D: Giving oxygen at 10L/min via nonrebreather face mask

The nurse is instructing a woman and her partner on non-pharmacological pain relief interventions such as effleurage and using heat/cold. The client asks how these techniques work to manage pain. Which is the best statement by the nurse? A: "Only a certain number of sensations can travel to the brain at once. We replace pain signals with pleasure signals to reduce discomfort." B: "Massage and heat reduce blood flow to tissues, and temporarily numb the nerve fibers." C: "The placebo effect makes the client believe their pain is less, even though there is no physiologic benefit of the techniques." D: "The effects are only useful in latent phase labor. As active labor starts, she will likely need opioid pain medication."

The nurse is preparing a client for a cesarean section. Following the epidural anesthesia, the nurse is ready to show the partner where to stay during the surgery. Where does the nurse show the partner to go? A: On a stool next to the client's head. B: On a stool next to the infant warmer. C: In a waiting room next to the operating room. D: In the recovery room, to await completion of the surgery.

The nurse midwife performs Leopold's Maneuvers to determine fetal positioning in the womb. which can the midwife determine by palpating the woman's fundus? A: If the fetus is breech or vertex B: The location of the back and fetal small parts C: The fetal presenting part D: The location of the cephalic prominence

The nurse is assessing a client's incision following a cesarean section. The dressing has just been removed. What findings would require further intervention? Select all that apply. A: Ecchymosis B: Warmth C: Edema D: Approximation E: Redness

A, B, C, E

Which nursing interventions would support a normal, physiologic birth? Select all that apply. A: Waiting until 40 weeks gestation to induce labor B: Assisting the mother to change positions frequently C: Collaborating with a doula or other support person to manage discomfort D: Encouraging the mother to lie on her back and place her feet in stirrups for delivery E: Allowing the bag of waters to rupture spontaneously

A, B, C, E

During assessment of a cesarean section incision, the nurse notes some concerns and decides to call the provider to report the findings. What findings would indicate a need for further nursing intervention? Select all that apply. A: Ecchymosis B: Edematous C: Approximated D: Redness E: Drainage free

A, B, D

During labor, nurses provide continuous support to clients. which are the outcomes seen from this support? Select all that apply. A: Decrease in operative births B: Increase in likelihood of breastfeeding C: Decrease in childbirth satisfaction D: Decrease in pharmacologic pain management E: Increase in labor length

A, B, D

The nurse assesses a patient who has an indeterminate fetal heart rate and places the patient on electronic fetal heart rate (FHR) monitoring. Which assessments are priorities from the electronic FHR monitoring? Select all that apply. A: Clarify the pattern interpretation B: Assess the baseline variability C: Confirm maternal heart rate with fetal heart rate D: Further assess fetal status E: Determine fetal movement

A, B, D

The nurse is caring for a client being augmented with oxytocin. What potential complications should the nurse observe the client for? Select all that apply. A: Tachysystole B: Late decelerations on the fetal monitor C: Episodic accelerations D: Uterine rupture E: Maternal edema

A, B, D, E

The nurse is preparing the client for epidural anesthesia. Which assessments or interventions would the nurse perform prior to administration? Select all that apply. A: Check the platelet level. B: Perform the procedure time-out. C: Determine that the client is dilated to at least 5cm. D: Ensure the consent has been signed. E: Administer IV fluid bolus of normal saline or lactated ringers.

A, B, D, E

The nurse is reviewing information of the fetal heart rate (FHR) baseline with a practicum student in labor and delivery. Which findings are correct regarding interpretation of FHR baseline characteristics? Select all that apply. A: Baseline FHR is the mean FHR rounded to increments of 5 bpm B: Normal range is 110-160 bpm C: Fetal tachycardia >200 bpm for at least 10 minutes D: Fetal bradycardia <110 bpm for at least 10 minutes E: Assess the baseline over a 10-minute period

A, B, D, E

The Labor and Delivery unit educator is teaching a group of nurses how to respond when a nurse assesses a patient that is demonstrating minimal or absent variability. Which responses by the nurses are correct regarding appropriate interventions? Select all that apply. A: Perform vibroacoustic stimulation B: Change maternal position C: Provide oxygen via nasal cannula D: Give an IV fluid bolus E: Discontinue oxytocin

A, B, D,E

The labor nurse is caring for a patient at risk for intraamniotic infection. Which assessment findings would alert the nurse of intraamniotic infection? Select all that apply. A: Baseline fetal heart rate 170 B: Maternal fever C: Meconium stained amniotic fluid D: Severe headache E: Foul-smelling vaginal discharge

A, B, E

The Labor and Delivery (L&D) unit educator discusses the prioritization of fetal monitoring goals, creating a plan of care, and setting goals for implementation with a group of nurses. Which goals are correct? Select all that apply. A: Interpretation of ongoing assessment of fetal oxygenation. B: Prevention of significant fetal academia. C: Minimize unnecessary interventions. D: Promote a satisfying family-centered birth experience. E: Use of EFM for all laboring women in the U.S. is required.

A,B,C,D

The Labor and Delivery (L&D) educator has explained to a group of nurses how the utero-placental unit functions. Which components are necessary for the fetus to receive appropriate oxygenation? Select all that apply. A: Adequate oxygenation of the mother B: Adequate uteroplacental circulation C: Adequate umbilical circulation D: Adequate fetal blood volume E: Adequate blood flow to the placenta

A,B,C,E

The nurse manager is working on a quality improvement project to improve patient outcomes during obstetrical emergencies. Which strategies would be included? Select all that apply. A: Improving communication between health care team members B: Developing written protocols for emergencies C: Implementing mock drills D: Using disciplinary actions when there is a poor outcome E: Educating nurses on early recognition of complications

A,B,C,E

There are several patients on the labor and delivery unit. Which patients are at risk for disseminated intravascular coagulation (DIC)? Select all that apply. A: Patient with term intrauterine fetal demise B: Patient with severe preeclampsia C: Patient with gestational diabetes D: Patient with twin pregnancy E: Patient with HELLP syndrome

A,B,E

A nurse is reviewing triggers from the Early Obstetric Warning System Chart after a client has had concerning changes in her condition. Which assessment findings would be classified as a red trigger? Select all that apply. A: Systolic BP < 90, >160 B: Maternal heart rate 100 to 120 (beats per minute) C: Respiratory rate 21 to 30 (breaths per minute) D: Oxygen saturation < 95% E: Diastolic BP > 100

A,D,E

A client is admitted to the labor and delivery unit in active labor. There has been no prenatal care for the current pregnancy, and the on-call provider estimates the pregnancy to be around 35 weeks' gestation. Which medication will the nurse anticipate being ordered for on this client? A: Oxytocin B: Penicillin C: Magnesium sulfate D: Metoclopramide

A mother-baby nurse just received report on four mother baby couplets and is preparing to start the first assessments of the shift. All are recovering from cesarean section deliveries. Which couplet will need to be seen first? A: Couplet #1: the infant and mother have been doing well since delivery 3 days ago and would like to be discharged in the next couple hours. B: Couplet #2: the infant has been breastfeeding successfully and the mother has required the uterine fundus to be massaged to firm. C: Couplet #3: the mother has chosen to bottle feed the infant, and the infant has lost 89 grams of the 3200-gram birth weight at 2 days of age D: Couplet #4: the infant has been experiencing difficulties latching on to breastfeed and last nursed successfully an hour and a half ago.

The nurse is assessing a patient who is 37 weeks pregnant and in active labor. The fetal heartrate is 130 BPM with moderate variability, no accelerations, no decelerations. The provider does a sterile vaginal exam on the patient which is 6/90/0 and ruptures the patient's amniotic sac (AROM). The nurse notes copious fluid coming from the vagina after the AROM and sudden repetitive and deep variables to the 80's and 90's. The nurse will base the needed nursing interventions on which of the following? A: This is normal after rupture of membranes and will resolve spontaneously as the fetus adjusts B: Deep variables may indicate a cord prolapse and the patient should be evaluated immediately. C: Variable decelerations indicate utero-placental insufficiency. D: Deep variables are also called prolonged decelerations.

The nurse is assessing several gravid patients for complications. Which patient is most likely to have oligohydramnios? A: G1P0 at 38 weeks gestation with Type 1 diabetes B: G2P0 at 42 weeks gestation being induced C: G6P5 at 39 weeks gestation with normal labor D: G2P1 at 40 weeks gestation having a trial of labor after cesarean (TOLAC)

The nurse is assessing the APGAR score on an infant at 1 minute of age. The infant has a lusty and vigorous cry with active motion of the extremities. The heart rate is 98 beats per minute. The respirations are 55 per minute, and the oxygen saturation is 98%. Acrocyanosis is noted on the hands and feet. which does the nurse record for the APGAR score? A: APGAR 10 B: APGAR 8 C: APGAR 9 D: APGAR 7

The nurse is reviewing the tracing of a patient who is pregnant with twins at 36 weeks gestation. which assessment data obtained by the nurse will require further evaluation? A: Baby A: FHR 110, moderate variability B: Baby B: FHR 130, minimal variability, two accelerations of 10 bpm for 10 seconds C: Contractions every 2 to 3 minutes palpated strong D: Resting tone palpated soft

Following a cesarean section, a client with asthma is concerned with developing post-operative pneumonia. What will the nurse include in the education on preventative measures during the first 12 hours after surgery? Select all that apply. A: Assessing lungs every four hours B: Utilizing the incentive spirometer regularly. C: Encourage cough and deep breathing regularly. D: Ambulate within 24 hours of surgery. E: Use oxygen when lying in bed.

B, C

A G1P0 patient is 40 weeks gestation and receiving an oxytocin infusion for labor induction. Which nursing actions are appropriate when late decelerations are identified on the fetal heart rate tracing? Select all that apply. A: Decrease the maintenance IV fluid rate B: Discontinue oxytocin C: Administer oxygen via non-rebreather face mask D: Notify the provider E: Place the woman in high Fowler's position

B, C, D

The nurse is teaching a class on uterine monitoring and the use of Montevideo units. which does the nurse include in the teaching related to the unit? Select all that apply. A: "They measure the frequency and duration of contractions." B: "They measure the intensity of the contraction." C: "They are calculated by adding the peak pressure for each contraction in a 10-minute period." D: "They help determine the adequacy of contractions." E: "They can be measured using the IUPC or external Tachometer."

B, C, D

The nurse has just gotten report on a patient who was admitted 2 days ago with premature rupture of membranes. The patient is now 6/90/0, FHR is 165BM with minimal variability >40 minutes, no accelerations, no decelerations. Amniotic fluid is cloudy and foul smelling and there is meconium. which are the appropriate nursing interventions for this patient? Select all that apply. A: Encourage ambulation B: Promote hydration C: Assess maternal vital signs D: Notify the provider E: Administer antibiotics and antipyretics as ordered

B, C, D, E

The nurse is reviewing the prenatal history of a post-term pregnant patient during an appointment in the provider office. It has been determined that the patient will need to be admitted for an induction. Upon reviewing the patient's history, which conditions does the nurse report to the provider that would prohibit the patient from having labor induction? Select all that apply. A: A lower transverse uterine incision from a previous cesarean section B: A vertical uterine incision from a previous cesarean section C: A history of a precipitous birth that occurred at home D: A fetus in the breech position E: A history of human papillomavirus infection (HPV)

B, D

The instructor is teaching the modes of fetal heart rate and contraction assessment to a class of nursing students. What are the modes of uterine monitoring? Select all that apply. A: Auscultation B: Palpation C: Fetal spiral electrode D: Intrauterine pressure catheter E: Tocodynamometer

B, D, E

The nurse is assessing a gravid patient having a trial of labor after cesarean (TOLAC). Which assessment finding would promptly be reported to the provider? A: Spontaneous rupture of membranes B: Fetal heart rate of 140 with early decelerations C: Ascending station of the fetal presenting part D: Unable to urinate after epidural placed

The nurse is teaching the patient about internal electronic fetal monitoring prior to the provider inserting the fetal scalp electrode. The patient begins crying and states, "I don't want a wire screwed in my baby's head!" Which is the most appropriate response by the nurse? A: "I will let the doctor explain the procedure to you, so that you understand how safe it is for your baby." B: "Internal monitoring is safe and will not cause the baby any harm." C: "Let me show you the tip that is placed superficially under the skin to monitor the baby's heart rate. We want you to understand the procedure." D: "I understand your concern. You can refuse the procedure if you are uncomfortable with it."

The nurse is training a new nurse in the labor and delivery unit. The trainee asks, "How often do we have to assess the fetal heart rate (FHR)?" The nurse instructs the trainee that the frequency of FHR assessment is based on: A: Patient preference B: Hospital census and staffing C: Risk status, stage of labor and clinical assessment D: Type of monitoring (SIA or EFM)

The physician is preparing to use forceps to assist a woman with a vaginal delivery. Which risk to the newborn would the nurse watch for? A: Hypoglycemia B: Sepsis C: Cephalohematoma D; Fractured clavicle

The process of labor is multifactorial. The five primary factors include powers, passage, passenger, psyche, and: A: Pressure B: Patience C: Position D: Pelvis

The provider wants to insert an intra-uterine pressure catheter (IUPC) into a pregnant patient. Which patient does the nurse recognize as the patient most likely to warrant placement of an IUPC? A: A patient with a category I tracing B: A patient progressing 2 cm an hour, but doesn't feel her contractions because of her epidural C: A patient whose membranes are ruptured, has an exam of 5/90/-2 and a worsening category II tracing D: A patient with a BMI of 40 in latent labor

Which patient with a fetus displaying minimal variability would the nurse assess first? A: A patient who received nalbuphine 10 mg slow IV push 10 minutes ago B: A patient who is 25 weeks gestation with intermittent contractions C: A patient who is 39 weeks gestation with 8 contractions in 10 minutes D: A patient who is 37 weeks gestation contracting every 6 to 7 minutes with no accelerations

A client reports a headache and dizziness following a scheduled cesarean section yesterday with spinal anesthesia. What does the nurse report to the provider as a concern for this client? A: Migraine headache B: Sinus infection C: Vertigo D: Spinal headache

Upon starting a shift in the labor and delivery unit, the nurse is assigned to care for a 15-year-old client in active labor. When entering the room to assess the client, the nurse finds a room full of visitors and notes the client appears uncomfortable. which is the appropriate nursing intervention at this time? A: Insist that all visitors leave the room so that it can be a quiet labor environment. B: Tell the client you will come back to check her blood pressure after everyone leaves. C: Determine who the visitors are, so the nurse can focus her assessment questions towards the parents of the client. D: Request that everyone step out during the assessment and ask the client whom she would like in the room for the birth.

Which plan would be most appropriate for monitoring a patient who presents to the labor and delivery unit in the active phase of labor with ruptured membranes? A: At least hourly by auscultation B: Every 30 minutes by electronic fetal heart monitoring C: Every 15-30 minutes by auscultation D: Every 15 minutes by electronic fetal heart monitoring

The nursery nurse is caring for a neonate who requires resuscitation. Place the resuscitation interventions given in the sequence in which the nurse will administer them. Provide positive pressure ventilation by CPAP. 2 Administer epinephrine to the neonate. 4 Reposition mouth and clear secretions from airway. 1 Perform coordinated chest compressions.3

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During labor and delivery, the fetus passes through the birth canal and must make several movements to allow for successful delivery. Place the following cardinal movements for birth into the correct order. Descent - 2 Expulsion - 7 Extension - 5 Flexion - 3 External rotation - 6 Engagement - 1 Internal rotation - 4

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A nurse is completing a bedside report on a patient who is being induced with oxytocin. The nurse checks the IV and notes that the patient is receiving 9 mL/hr of oxytocin that is supplied as 20 units in 1000 mL of lactated Ringer's solution. Which is the infusion rate of the oxytocin in mU/min? Enter the numerical value only.

Per provider order, the nurse is preparing to administer oxytocin to a client who is in the third stage of labor. The order is for 20 units of oxytocin in 1,000 milliliters of Lactated Ringer's, and the client is to receive a 10-unit bolus over one hour. At what mL/hr will the IV pump be programmed to for the administration of this bolus dose? Enter the numeral only.

500

The nurse is assessing a client who has just delivered a baby and calculates the initial blood loss from delivery to be 338 g. Over the next couple of assessments, the nurse changes the chux pads under the client due to bleeding. The chux pads weigh 128 and 242 g. The nurse knows that the client has had an estimated blood loss of how many milliliters? Report your answer in mL. Enter only the numerical value.

708

The nurse is calculating total estimated blood loss for an eight-hour shift on a client. The client is recovering from a c-section on the previous day. The nurse has documented the following weights for four pads during the shift: 153 g, 208 g, 92 g, and 346 g. What is the total estimated blood loss in mL for the client during the shift? Enter numerical value only.

799

A patient receives oxytocin, 6 mL/hr for 30 minutes, 8 mL/hr for 30 minutes and 10 mL/hr for 15 minutes. The solution prepared in the pharmacy is 10 Units/1 Liter. How many units of medication did the patient receive in total? Enter the numerical value only.

A client is pregnant with her second child following a cesarean section delivery with the first pregnancy for a breech fetal position. The couple plans to have three children total. What option does the nurse discuss as the best one for this couple? A: Vaginal birth B: Repeat c-section C: External cephalic version D: Only having two children

A client was recently admitted to the labor and delivery unit in active labor. The nurse performs Leopold's maneuvers during the assessment. During the third maneuver, the nurse notes a firm and fixed fetal part. Which position correlates with this assessment finding? A: Occiput B: Acromion C: Sacrum D: Transverse

A group of pregnant women in the third trimester of pregnancy are attending a childbirth education class. When teaching about the differences between true labor and false labor, what would the nurse note about false labor? A: The cervix does not dilate. B: The contractions get stronger. C: The cervix becomes thinner. D: The contractions get closer together.

A laboring patient is experiencing labor dystocia. Which statement correctly describes labor dystocia? A: Difficult labor characterized by abnormally slow labor progress B: Fetal shoulder impacted under the maternal symphysis pubis C: Fetal head larger than maternal pelvis D: Uterine contractions >25 mm Hg with intrauterine pressure catheter

A nurse is caring for a client following a cesarean section delivery the day before. During the assessment, the nurse checks for Homan's sign. Why is the nurse conducting this assessment? A: There is an increased risk of thromboembolism after surgery. B: This assessment checks for wound healing on the surgery site. C: It is important to check for peripheral circulation following surgery. D: Constipation is a risk after a cesarean delivery.

A nursing instructor explains to a group of students that an amnioinfusion is a procedure used most commonly in the first stage of labor to treat which type of decelerations? A: Variable B: Late C: Early D: Prolonged

Following a cesarean section a few hours ago, the partner of a client comes out to the nurses' station to report severe itchiness the client is experiencing. The partner voices concern that the client is experiencing an allergic reaction to the morphine given during surgery. How does the nurse respond to the client when entering to the room to assess the itching? A: "Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy." B: "Here is some medication to stop the itching." C: "I will note in your medical record that you have an allergy to morphine." D: "Let me call the provider and report the itching."

The nurse is assisting a client who is in early labor and experiencing intense back pain with nonpharmacologic pain management. Which technique can the nurse implement for this client? A: Counter pressure over the sacral area B: Effleurage over the abdomen C: Use of an ice pack over the forehead D: Playing music that is upbeat

The nurse is caring for a patient who is exhibiting the decelerations circled in the following picture. which does the nurse assess related to the decelerations pictured? A: Early Decelerations caused by head compression B: Early Decelerations caused by cord compression C: Late Deceleration caused by utero-placental insufficiency D: Variable Decelerations caused by head compression

The nurse is caring for a patient who was just admitted to the labor and delivery (L&D) unit. Her exam is 6/90/0. The initial fetal heart monitor (FHM) strip is Category I. Her pregnancy was complicated by gestational diabetes mellitus (GDM), well controlled with diet. The nurse will base assessment interventions related to the frequency of assessment of the FHR for this patient on The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), which is? A: Every 15 minutes during the active phase and every 5 minutes for the second stage B: Every 30 minutes during the active phase and every 15 minutes for the second stage C: Every 60 minutes during the active phase and every 30 minutes for the second stage D: Every hour, on the hour

The nurse observes the following strip for a patient. which would the nurse document related to this strip? A: Frequency every 1.5 minutes lasting 50-70 seconds B: Frequency every minute lasting 90 seconds C: Frequency every 110 seconds lasting 90 seconds D: Frequency every 110 seconds lasting 50 seconds

The nurse performs Leopold's maneuvers on a patient prior to auscultating the FHR with a handheld doppler. The nurse palpates the fetal head at the fundus and the presenting part is not engaged. Where would the nurse position the doppler to evaluate the FHR? A: Upper fundal area B: Right lower abdomen C: Left lower pelvis D: Near umbilicus

Upon vaginal examination, the nurse notes that the infant's anterior fontanel is to the back left side of the maternal pelvis. How does the nurse chart this position? A: ROA B: LOA C: ROP D: LOP

While assessing a pregnant patient, the nurse notes the fetal heart rate (FHR) is 125 with moderate variability, no accelerations and no decelerations. Using the National Institute of Child Health and Human Development (NICHD) Criteria, which would the nurse record as the appropriate category related to the assessment findings? A: Category I: Strongly predictive of a well- oxygenated, non-acidotic fetus. No action required. B: Category II: Indeterminate. Requires continued surveillance and reevaluation. C: Category III: Abnormal requiring prompt evaluation and intervention. D: Category IV: Fetal Demise.

While the nurse is preparing a client for an emergency cesarean section, the family voices concern that the client is extremely nervous about the procedure. How does the nurse respond to the client? A: "Tell me about how you are feeling right now." B: "We do many c-sections every day, you will be fine." C: "I am going to insert the foley catheter now." D: "It is important that you try to calm down for the baby."

The patient asks the nurse what can be detected with external electronic fetal and uterine monitoring. which is the appropriate nursing response? Select all that apply. A: Fetal Heart Rate (FHR) baseline and variability B: Fetal Heart Rate (FHR) accelerations and decelerations C: The frequency and durations of contractions D: Fetal station and position E: The pressure and intensity of contractions

A, B, C

The nurse notes that a patient receiving oxytocin had six uterine contractions in 10 minutes, three of which occurred within 1 minute of each other. In which order should the nurse provide care to this patient? A: Reposition the patient. B: Discontinue oxytocin infusion. C: Reduce oxytocin infusion by half. D: Apply oxygen 10 L/min via nonrebreather mask. E: Provide intravenous fluid bolus of 500 mL lactated ringers.

A, B, C, D, E

The nurse is performing preoperative care on a client scheduled for cesarean section. Which nursing actions should be performed? Select all that apply. A: Insert an IV catheter B: Administer sodium citrate C: Trim pubic hair D: Insert straight catheter E: Apply sequential compression devices

A, B, C, E

Which assessments of uterine activity are obtained by the nurse when the patient has an intrauterine pressure catheter (IUPC) placed? Select all that apply. A: Frequency B: Intensity C: Duration D: Fetal Heart Rate E: Resting Tone

A, B, C, E

The nurse is assisting a pregnant client, who is placing the baby up for adoption, with the development of a birth plan. which questions would the nurse consider when planning the birth plan? Select all that apply. A: Will the client spend some time alone with the infant? B: How involved will the adoptive parents be in the birth? C: Does the client plan to leave the hospital immediately after delivery? D: Where are the closest support groups for birth parents? E: Who will be present at the hospital to support the client?

A, B, D, E

The operating room nurse is ready to conduct the "time out" process before the start of the cesarean section on a client. What will the operating room staff confirm during this process? Select all that apply. A: Right patient B: Right procedure C: Right time D: Right gestation E: Right site

A, B, E

The obstetrician and nurse are inspecting the placenta and umbilical cord following a delivery. Which abnormal assessment findings require further assessment of the infant? Select all that apply. A: The umbilical cord contains one vein and one artery. B: The cord inserts into the placenta in the middle of the shiny side. C: The umbilical cord has one knot in it. D: The dirty side of the placenta appears to have all parts. E: The umbilical cord is filled with Warton's Jelly.

A, C

While presenting an educational session on childbirth the nurse was asked to discuss risk factors requiring a cesarean section. What should the nurse include in her response? Select all that apply. A: Advanced maternal age B: Spontaneous labor onset C: Breech position D: Maternal request E: Multiparity

A, C

Following a precipitous labor, the obstetrician did not arrive to the hospital in time for the delivery. The nurse is monitoring for the delivery of the placenta. Which indications would result in the nurse asking the client to push to deliver the placenta? Select all that apply. A: A sudden gush of blood from the vagina B: Client starts to feel very nauseous C: Umbilical cord lengthens at the vaginal introitus D: Uterus rises upward in a ball shape E: Blood pressure and pulse rate decrease

A, C, D

The nurse is preparing a group session for childbirth preparation. The topic will include signs of impending labor. The nurse will include which topics? Select all that apply. A: Lightening B: Decreased fetal movement C: Nesting D: Bloody show E: Weight gain

A, C, D

While caring for a client and family the day of a cesarean section, which considerations can be implemented by the nurse to decrease the anxiety level for all? Select all that apply. A: Answer any questions that the client and family may have during the day. B: Be sure to have the charge nurse come speak with the family. C: Discuss what to expect in the operating room. D: The same nurse should care for the client throughout the shift. E: Give the client an anti-anxiety medication to decrease the anxiety level.

A, C, D

The nurse is caring for a gravid patient in labor who is 7 cm dilated and experiencing slow labor progress. Which factors can contribute to labor dystocia? Select all that apply. A: Maternal exhaustion or fear B: History of precipitous birth C: Hypertonic uterine dysfunction (tachysystole) D: Occiput anterior presentation E: Analgesia early in labor

A, C, E

The nurse is receiving a report on a patient and notes that the patient's exam is 8/90/+2, with contractions every 2-3 minutes and lasting 70-90 seconds. The FHR is 145 bpm with minimal variability and repetitive late decelerations to 110's, lasting 60-100 seconds. which are the appropriate nursing interventions for this patient? Select all that apply. A: Administer 02 at 10L/min via non-rebreather mask B: Begin oxytocin at 2mu/min to hasten delivery C: Position patient on either side. D: Limit IV fluids to prepare for cesarean section and prevent fluid overload E: Notify the provider

A, C, E

The provider orders an amnioinfusion for a patient who is a G2P1 at 40 weeks gestation. which education would the nurse provide to the patient? Select all that apply. A: Explain placement of intrauterine pressure catheter into the uterus. B: Explain that the procedure is performed to resolve all types of decelerations. C: Explain that room temperature sterile IV fluids are infused to cushion the umbilical cord. D: Inform patient that she will remain flat until infusion is completed. E: Discuss that fluid will continue to leak vaginally and should be monitored to prevent over-distention.

A, C, E

The nurse is providing discharge instructions to a client and family following a cesarean section delivery three days ago. The family is unsure how to help the client at home. What does the nurse include in the education? Select all that apply. A: Bring meals to the family. B: Do not visit for three weeks. C: Take infant for a walk each day. D: Offer to do housework. E: Feed the infant for the mother.

A, D

During a childbirth education class focused on labor and delivery, the nurse is discussing Cesarean Delivery on Maternal Request. What neonatal complications does the nurse include when addressing deliveries earlier then 39 weeks' gestation? Select all that apply. Respiratory distress A: Hypothermia B: Hysterectomy C: Feeding intolerance D: Hypoglycemia E: Respiratory distress

A, D, E

A nurse is preparing to assist a new mother with breastfeeding following a cesarean section delivery. Which positions will the nurse recommend to maximize patient comfort while breastfeeding? Select all that apply. A: Side-lying position B: Cradle hold C: C-cup positioning D: Using a breast pump E: Football hold

A, E

A gravid patient with diabetes is in labor with suspected macrosomia. Which nursing actions would be done to prepare for the delivery? Select all that apply. A: Notify the surgical team of the potential for an operative delivery. B: Have an additional nurse available to assist with a shoulder dystocia. C: Gather neonatal supplies for a small baby. D: Have catheter available to empty bladder. E: Anticipate the need for postpartum oxytocic medications.

A,B,D,E

A patient had an operative vaginal delivery with forceps. Which maternal complications would the nurse assess for? Select all that apply. A: Perineal hematoma B: Cesarean incision infection C: Hemorrhage D: Urinary retention E: Hyperreflexia

A,C,D

During a birth, the nurse notes the fetal head retracts against the maternal perineum after delivery of the head. Which nursing actions would the nurse implement? Select all that apply. A: Perform McRoberts maneuver. B: Apply fundal pressure. C: Apply suprapubic pressure. D: Assist the provider in pulling harder on the fetal head. E: Request the mother not to push until directed by the provider.

A,C,E

The nurse is describing baseline fetal heart rate (FHR) to a practicum student. which would the nurse mention when teaching about the definition and assessment criteria related to baseline FHR? Select all that apply. A: "Periodic changes in baseline of FHR occur in relation to uterine contractions." B: "Recurrent changes in baseline of FHR occur in less than 50% of the contractions in 20 minutes." C: "Intermittent changes in baseline of FHR occur in greater than 50% of the contractions in 20 minutes." D: "Episodic changes in baseline of FHR occur independent of uterine contractions." E: "FHR is rounded to increments of 5 beats per minute during a 10-minute window. This must be at least 2 minutes of identifiable baseline segment."

A,D,E

After assessing a patient, the nurse records the following findings: FHR 145BPM with moderate variability. The patient is contracting with a frequency of every 3 minutes and duration of 60-75 minutes, with intermittent decelerations to 125 bm beginning 10 seconds after the peak of a contraction and lasting 50-70 seconds with a baseline to nadir interval greater than 30 seconds. Which does the nurse record to describe the decelerations? A: Late deceleration B: Early deceleration C: Variable deceleration D: Prolonged deceleration

A 39-week gestation client calls the office to report increased vaginal mucus discharge and urinary frequency. She states there is good fetal movement. Which would the nurse explain to the client? A: This is likely a urinary infection. B: These are signs of impending labor. C: She should use a vaginal douche to clear the mucus discharge. D: The baby will have a drastic decrease in movement as labor approaches.

A new labor and delivery nurse is working with a preceptor to prepare a client for a cesarean section delivery. There is a fetal scalp electrode in place to monitor the fetal heart rate. When does the preceptor advise the new nurse to remove the scalp electrode? A: Right after the infant is delivered during the surgery B: After the abdominal prep for surgery C: Prior to placement of the epidural anesthesia D: Prior to transfer to the operating room

A nurse is admitting a diabetic patient with decreased fetal movement at 39 weeks gestation. As the nurse adjusts the tocodynamometer (toco) and ultrasound transducer on the patient, a fetal heart rate in the 80's is noted. Which is the most appropriate nursing action? A: Readjust the ultrasound and toco B: Confirm maternal heart rate to FHR C: Call for an ultrasound D: Call the provider

A nurse is caring for a client following a cesarean section four hours ago that occurred due to arrest of labor. Initially, the client was admitted to the hospital two days ago after experiencing spontaneous rupture of membranes. Which medication order does the nurse anticipate for this client? A: Bisacodyl B: Ampicillin C: Methergine D: Dexamethasone

A pregnant woman is admitted to triage and states her contractions are "really strong." The nurse palpates her contractions and finds her uterus is resistant to indentation. The nurse would chart her contractions as which? A: Weak B: Moderate C: Strong D: Intractable

A term laboring patient is reporting severe lower back pain and has been pushing for two hours. The nurse would anticipate that the fetus is in which position? A: Frank breech B: Occiput posterior C: Occiput anterior D: Shoulder presentation

A woman in the second stage of labor has been pushing for 3 hours. The provider is preparing for a vacuum-assisted delivery. Which anticipatory guidance should the nurse give to the patient? A: "The blades of the forceps will be applied to the fetal head." B: "The baby may have some bruising and edema of the head." C: "You will need to push between contractions." D: "An episiotomy is required for a vacuum delivery."

During a childbirth education class, a patient asks about "stripping of membranes." Which is the best explanation of this? A: This is breaking the bag of water. B: This is separating the membranes from the cervix to stimulate labor. C: This is to manually remove the placenta. D: This is done if the placenta is covering the cervix.

During a childbirth education class, the nurse educator describes signs of impending labor. Which statement made by a class participant requires further teaching? A: "I may experience a sudden surge of energy, or a 'nesting' instinct, as labor approaches" B: "It may be more difficult to breathe as the baby gets larger toward my due date." C: "It's normal to experience warm-up contractions that aren't painful before the real thing." D: "I could feel some increasing lower back and hip discomfort"

The Labor and Delivery educator is teaching a group of new nurses the overall goals of fetal monitoring. Which response by the new nurses indicates that the educator should provide further education? A: "Support maternal coping and labor progress." B: "Support coached pushing." C: "Maximize oxygenation." D: "Maximize umbilical blood flow."

The anesthesiologist reviews the blood work for a client scheduled for a cesarean section and determines that an epidural or spinal anesthesia are not possible. The nurse explains which lab result to the client as the reason for this determination? A: White blood cell 9.8 th/mm3 B: Platelet 99 th/mm3 C: Hemoglobin 12.7 g/dL D: Red blood cell 5.1 mil/mm3

The fetus of a patient in labor is in the occiput posterior position. For which manifestation should the nurse plan care for this patient? A: Severe abdominal pain B: Prolonged second stage of labor C: Accelerated uterine contractions D: Premature rupture of membranes

The grandmother of a newly-delivered infant was in the room for the delivery. The newborn is placed skin-to-skin with the mother and covered with a warm blanket while waiting for the placenta to deliver. The grandmother expresses concern that the newborn is too cold with no clothes on. Which is the best response by the nurse? A: "I will check the temperature when I have time." B: "Skin-to-skin contact helps newborns to regulate temperature." C: "Please just stand out of the way of the provider." D: "The warm blanket will stop all cold air from reaching the baby."

The midwife is explaining to the patient how to palpate contractions during labor. The midwife explains that in between contractions the uterus should feel soft. Which is the midwife assessing between contractions? A: Intensity B: Resting tone C: Frequency D: Duration

The nurse assesses that the patient has uteroplacental insufficiency based on the strip. Which of the following fetal heart monitor (FHM) strips assisted the nurse in this assessment? A: MAT3-FHRACOMP-38-01.jpg B: MAT3-FHRACOMP-38-02.jpg C: MAT3-FHRACOMP-38-03.jpg D: MAT3-FHRACOMP-38-04.jpg

The nurse calls the provider on a cesarean section client the day after surgery to report concerns about peristaltic ileus. What assessment data does the nurse include in the report to the provider to support this concern? A: Foul smelling discharge from the incision B: Absent bowel sounds in the lower right quadrant C: Temperature of 101.3℉ and 102.1℉ and hour later D: Redness, pain, and swelling in the left calf

The nurse calls to notify the provider that the patient has a Category II tracing. Which would the nurse include in her charting that was interpreted from the tracing? A: Absent variability, FHR 120, recurrent variable decelerations B: Minimal variability, FHR 165, recurrent variable decelerations C: Early decelerations, FHR 145, moderate variability D: No accelerations, FHR 110, moderate variability

The nurse caring for a G4P3 patient in active labor. Her fetus continues to have late decelerations with minimal variability despite interventions and notifies the provider on call. The provider gives an order to continue with the current plan of care. Which is the nurse's priority at this time? A: Advise the patient that another provider will be notified because of the concerns for the fetus. B: Use the chain of command and communicate the FHR findings clearly to the charge nurse or next provider. C: Document the conversation with the provider using objective language and continue a close observation of the fetus. D: Discuss concerns with another nurse in the department.

The nurse is auscultating the fetal heart rate on a patient who states her fetus is breech at 32 weeks gestation. Which is the appropriate nursing action to perform the auscultation? A: Place the doppler in the upper abdomen to locate the area of maximum intensity of fetal heart tones. B: Palpate the maternal abdomen to determine fetal position. C: Explain the procedure to the woman and her family. D: Confirm fetal position by ultrasound.

The nurse is caring for a client in the latent phase of labor who is requesting pain medication. which is the appropriate nursing response regarding the administration of pain medication for this client? A: "I will call the provider and obtain an order for the medication." B: "It is best to wait until active labor. I can show you some pain management techniques." C: "The provider never gives pain medication this early in labor." D: "It is way too soon for that. You have a lot of time in labor to go."

The nurse is caring for a client using a labor doula. While collaborating for the client's care, which activity would not be delegated to the doula? A: Assisting the woman to ambulate in the hall B: Auscultating fetal heart tones while the woman uses the whirlpool C: Applying heat and cold to the woman's lower back D: Advocating for the woman's birth plan to be followed

The nurse is caring for a client who delivered a nulliparous pregnancy via cesarean section late the day before. The client is requesting eggs for breakfast. The grandmother is concerned with the client eating a regular diet so soon after surgery. How does the nurse respond to the concern? A: "That is not how we do it anymore." B: "Eating actually helps with return of bowel function." C: "Research changes how things are done frequently." D: "It is best to always give the client what they want."

The nurse is caring for a client who has been dilated to 10 cm for about one hour. When assessing the client, her mother asks why the nurse has not started telling her daughter to push. Which is the appropriate response from the nurse? A: "Times are different now, we do not make women push if they do not want to." B: "The baby does better at birth if the mother waits to push once she feels the urge." C: "It is best to start pushing one hour after reaching full dilation. It will start soon." D: "The provider is not here yet, so pushing must be delayed."

The nurse is caring for a patient following a precipitous delivery. Which complication would the nurse watch for? A: Retained placenta B: Postpartum hemorrhage C: Hemorrhoids D: Uterine rupture

The nurse is caring for a patient that is being induced with oxytocin. Upon assessment of the oxytocin infusion and patient status, the nurse would determine effectiveness with which clinical finding? A: The patient reports a pain level of 4 on the numeric pain scale with bloody show noted on the peripad. B: Contractions last 40 to 60 seconds every 2 to 3 minutes with cervical change. C: Contractions are 4 to 5 minutes apart lasting 30 to 40 seconds with no cervical change. D: Intensity of contractions is at least 75 to 100 mm/Hg with IUPC.

The nurse is caring for a patient whose fetus has been diagnosed with Intrauterine Growth Restriction (IUGR). The patient asks the nurse how this could have happened. Which does the nurse recognize as a possible cause? A: The fetus has a lower oxygen tension then an adult. B: Available oxygen chronically falls below 50% of normal levels and there is a redistribution of blood to vital organs. C: The amount of lactic acid exceeds fetal buffering capacity. D: Oxygenated blood from the mother is delivered to the intervillous space in the placenta.

The nurse is caring for a patient with a birth plan who requested in the active phase of labor to be monitored without continuous electronic fetal monitoring (EFM). How often would the nurse intermittently assess the fetal heart rate? A: Every 1 hour by auscultation B: Every 5-30 minutes by auscultation C: 10-30 minutes every 1-2.5 hours with EFM D: Every 15 minutes with EFM

The nurse is caring for a patient with preeclampsia who has oligohydramnios. When developing the plan of care, which interventions would promote maternal-fetal exchange of oxygen during labor? A: Insert an intrauterine pressure catheter for amnioinfusion B: Maternal positioning C: Monitor blood pressure D: Provide oxygen at 10L per nonrebreather facemask

The nurse is evaluating the fetal heart rate baseline and variability in the tracing. which would the nurse document and report to the provider? A: Baseline 135, moderate variability B: Baseline indeterminate, marked variability C: Baseline 130, marked variability D: Baseline indeterminate, moderate variability

The nurse is preparing a client in the operating room for a cesarean section. The client asks the nurse why a roll is being placed under the hip. How should the nurse respond? A: "The hip tilt position allows the provider easier access to the uterus for delivery." B: "The hip tilt position eases pressure on the inferior vena cava and decreases the risk of hypotension." C: "The hip tilt position decreases bladder distention and reduces the risk of bladder injury during surgery." D: "The hip tilt position allows for a quicker delivery of the infant during the c-section."

The nurse is preparing to transport a client accompanied by her partner to the operating room for a cesarean section. The client wears eyeglasses that must be removed. Where should the nurse place the glasses? A: In the nightstand drawer B: With the partner C: In the safe in the room D: With the client

The nurse is providing education to a client on when the Intravenous Catheter can be discontinued following a cesarean section. What information will the nurse include? A: Client has adequate pain control with oral medication. B: Client can maintain oral hydration without nausea. C: Client has active bowel sounds in all four quadrants. D: Client is breastfeeding infant well every couple of hours.

The nurse notifies the provider that the patient has a Category III tracing and discontinued the oxytocin. The provider orders the nurse to restart the oxytocin infusion. Which is the most appropriate action by the nurse to minimize risks to the patient? A: Refuse to restart the oxytocin. B: Communicate concerns to the provider about restarting oxytocin and use the chain of command if necessary. C: Restart the oxytocin as ordered. D: Document the communication and concerns that were discussed, then restart the oxytocin as ordered.

This image shows a priority nursing action for which obstetrical emergency? A: Uterine inversion B: Prolapsed umbilical cord C: Shoulder dystocia D: Face presentation

To decrease the risk of bleeding following a cesarean section, the nurse administers which medication to the client following delivery of the infant? A: Cefozolin B: Oxytocin C: Famotidine D: Magnesium sulfate

Upon admission, the nurse instructed a 39-week gestation client to lie on her back in bed for assessment and placement of the fetal monitor. After going through the medical history, the nurse assesses the client's blood pressure at 76/42. Which is the appropriate intervention? A: Retake the blood pressure with a manual cuff. B: Move the client onto her left side. C: Call the provider to obtain an order for IV fluids. D: Continue to monitor blood pressure every 30 minutes.

When palpating the patient's fundus during a contraction, the nurse notes that it feels like a 'chin.' The nurse documents this finding as which contraction intensity? A: Mild B: Moderate C: Strong D: Firm

Which fetal monitor tracing represents tachysystole? A: Top image B: Middle image C: Bottom image D: None of these represent tachysystole

While assessing a post-operative cesarean section client, the nurse notes a temperature of 102.1?. Prior to calling the provider, what other assessment should the nurse complete to include when reporting the concern? A: Identify the time of last pain medication B: Assess the c-section incision C: Assess lung sounds and incentive spirometry D: Assess uterine fundus and lochia

The nurse is rapidly determining the need for resuscitation immediately following delivery of a 36-week infant. The nurse must answer yes to which questions to determine that skin-to-skin contact is appropriate? Select all that apply. A: How long was the mother in labor? B: Is the infant a term gestation? C: Does the newborn have good muscle tone? D: Is the baby crying and breathing? E: Were medications given during labor?

B, C, D

The nurse is assessing a laboring client. Which signs and symptoms does the nurse recognize that indicate movement into the transition phase of labor? Select all that apply. A: Contractions every 3 to 4 minutes B: Contractions lasting 60 to 90 seconds C: Cervix dilated to 8 cm D: Noted trembling of client E: Increase in client anxiety

B, C, D, E

The charge nurse is observing a new nurse on the labor and delivery floor caring for a client in active labor and recognizes the need for additional training. Which care provided by the new nurse demonstrates a need for further orientation? Select all that apply. A: The new nurse encourages client to use the restroom every hour. B: The new nurse recommends client stay in bed and rests until it is time to push. C: The new nurse explains all procedures to the client throughout the shift. D: The new nurse suggests that all family members leave the room. E: The new nurse assists client with breathing techniques to help with relaxation.

B, D

The nurse is teaching a childbirth education class. Which statements regarding induction of labor would be included in the teaching? Select all that apply. A: Labor induction is used only for medical reasons. B: Prior to using oxytocin for labor induction, the cervix should be favorable. C: As long as you are over 37 weeks gestation, your doctor may induce you for convenience. D: The risks of labor induction are the same as the risks with spontaneous labor. E: You should not have a labor induction if you have active herpes.

B, E

The cervix of a patient in labor is not dilating. For which reason would mechanical ripening be contraindicated for this patient? Select all that apply. A: Gestational diabetes B: Fetal malpresentation C: Unexplained vaginal bleeding D: History of prior traumatic injury E: Premature rupture of membranes

B,C,D

The nurse has just completed a fetal monitoring course and is explaining the normal findings of structured intermittent auscultation (SIA) with a handheld Doppler. Which would the nurse identify as a normal finding of SIA? Select all that apply. A: Moderate variability B: Normal baseline between 110 to 160 bpm C: Regular rhythm D: Presence of FHR increases from baseline E: Absence of FHR decreases from baseline

B,C,D,E

The nurse is caring for a gravid patient who was admitted for cervical ripening prior to her induction of labor. Which statements are correct regarding cervical ripening agents? Select all that apply. A: Misoprostol (Cytotec) dose of 800 mcg should be given every 3 to 6 hours. B: Prostaglandins should be avoided in women with prior uterine surgeries. C: A balloon catheter is a mechanical method of cervical ripening and is an option in women with prior uterine incision. D: Cervidil (Dinoprostone) can be removed quickly if tachysystole occurs. E: Misoprostol (Cytotec) is inserted in the vaginal fornix.

B,C,D,E

The nurse is preparing to administer an oxytocin infusion for labor induction for a patient who is post-term. Which of the following are true regarding oxytocin for induction of labor? Select all that apply. A: The starting dose is 5 to 10 mU/min. B: The dose is increased by 1 to 2 mU/min every 30 to 60 minutes, until adequate labor progress is achieved. C: Oxytocin can be given via IV infusion or by IM injection for induction. D: Tachysystole is a potential side effect. E: Water intoxication can occur.

B,D,E

A client calls for the nurse to come to the room the day after a cesarean section delivery. Upon arrival to the client's room, the nurse notes that the client is dyspneic and appears short of breath. The client reports that her chest feels tight. Based on these assessment findings, what does the nurse report to the provider? A: Postpartum hemorrhage B: Wound infection C: Pulmonary embolism D: Wound dehiscence

A client is requiring a rubella vaccination before discharge following cesarean section delivery of a 34-week gestation female infant. The infant is in the Neonatal Intensive Care Unit. The nurse is explaining why the immunization is required. What should be included in the explanation? A: Rubella vaccine is given to parents of premature infants. B: The mother must not have been vaccinated as a child. C: The mother's blood work demonstrated a non-immune status. D: This is a normal booster vaccine given to all adults.

A gravid patient is receiving oxytocin for augmentation of labor. The oxytocin infusion has been running at 6 mU/min for 30 minutes. Uterine contractions are every 2 to 3 minutes, lasting 60 seconds, intensity of 60 mm/Hg with IUPC. There has been some cervical change since the last exam, and the FHR is normal. Which nursing action is most appropriate at this time? A: Increase the oxytocin dose to 12 mU/min. B: Increase the oxytocin dose to 8 mU/min. C: Leave the oxytocin at the current dose. D: Decrease the oxytocin to 4 mU/min.

A laboring woman was just assessed by the nurse and found to be 8 cm dilated. She calls the nurse back in the room, stating, "I feel pressure, and I think the baby is coming." Which nursing action has the highest priority? A: Explain to the patient that she is not yet completely dilated, and it is normal to feel rectal pressure. B: Call the attending provider. C: Perform a cervical exam. D: Assist her to the bathroom to relieve her bowels.

A new mother is refusing all medications for her newborn infant. The obstetrician has asked the nurse to explain the purpose of the Vitamin K injection to the parent. How would the nurse explain the need for this medication? A: "This medication will help prevent infections in the eyes due to bacteria in the birth canal." B: "All medications are required in our state, so you will not be able to refuse this medication." C: "This medication is given because the infant does not yet have good bacteria in the gut to help with clotting." D: "This medication is the first of several that will prevent viral liver disease."

A nurse is completing an assessment on a client following a cesarean section delivery the day before. The client appears to be short of breath. Vital signs are as follows: Temperature 98.5?, Pulse 62, Respirations 42, Blood pressure 102/74, and Pulse oximetry 88%. Based on these assessment findings, what concern does the nurse relay to the provider? A: Uterine infection B: Postpartum hemorrhage C: Pulmonary embolism D: Disseminated intravascular coagulation

A nurse is completing an assessment on a client following a cesarean section the day before. The client appears short of breath and vital signs are as follows: Temperature 98.5?, Pulse 62, Respirations 42, Blood pressure 102/74, and Pulse oximetry 88%. What concern does the nurse relay to the provider? A: Uterine infection B: Postpartum hemorrhage C: Pulmonary embolism D: Disseminated intravascular coagulation

A nurse is performing a physical assessment on a newborn who was born 6 hours ago via a vacuum-assisted vaginal birth. The mother states, "I am concerned about the cephalohematoma on my baby's head. Can you tell me more about the condition?" Which statement would be most appropriate by the nurse? A: "No need to worry. Cephalohematoma is caused by the cranial bones changing shape to get through the maternal pelvis." B: "Cephalohematoma is a concern and I need to call the pediatrician right away." C: "Although cephalohematoma is self-limiting, it can put your baby at risk for jaundice." D: "Cephalohematoma only occurs with vacuum-assisted birth; I'm sure it will be fine."

A patient has been diagnosed with intrauterine inflammation or infection (Triple I) during labor. Which assessment finding by the nurse would correlate with the Triple I diagnosis? A: Bloody show on perineum B: Fetal bradycardia C: Fetal tachycardia D: Maternal temperature 99.5 F

A patient has been laboring for over 18 hours when the provider ruptures her membranes. The fetus experiences a prolonged deceleration immediately following the procedure. Which is the priority nursing action for this patient? A: Notify the provider. B: Administer an IV fluid bolus. C: Change the maternal position. D: Perform a vaginal exam.

A patient in labor is noted to have an occiput posterior presentation. Which complications would the nurse anticipate? A: Prolapsed cord B: Facial bruising in neonate C: Dystocia D: Shortened second stage

A provider has determined a client needs a cesarean section for cephalopelvic disproportion. The client asks the nurse to explain what cephalopelvic disproportion means. What is the best response by the nurse? A: "You are needing a c-section due to the baby experiencing stress from labor." B: "Let's focus on preparing for the surgery." C: "The baby is too large for your pelvis." D: "Have you had a recent ultrasound to estimate the baby's weight?"

During a scheduled cesarean section for placenta accreta, the client required a hysterectomy due to failure of the placenta to separate. The gravida 1 para 1 client delivered a healthy baby boy. What concern does the nurse anticipate addressing with the client? A: Family dysfunction B: Postpartum psychosis C: Postpartum depression D: Ineffective bonding

Following cesarean delivery, a stable female infant weighing 3,126 grams is placed skin-to-skin with the mother. The client's partner asks why the infant is placed with the mother during the remainder of the surgery. What is the best response from the nurse? A: "Placing the infant with the mother reduces the need to have another nurse in the crowded operating room." B: "We can discuss this later, I need to help the surgeon right now." C: "Infants are less likely to need NICU care when placed skin-to-skin with the mother." D: "It is important to get a picture immediately after delivery of the infant."

Following the assessment of a newly-admitted laboring client, the nurse documents the client to be 4cm, 30%, and -3 with contractions every 4 to 5 minutes and lasting 45 seconds. which phase of labor does the nurse assess the client to be in? A: Second stage B: Third stage C: Latent phase D: Transition phase

Immediately following the delivery of the placenta, the nurse prepares to administer IV oxytocin. The client states, "What is this medication for?" which is the nurse's best response? A: "To augment labor contractions" B: "To improve the let-down reflex for your breastmilk." C: "To prevent hemorrhage after delivery." D: "To prevent uterine cramping and pain following delivery."

In addition to assessing bowel sounds, what other priority gastrointestinal assessment should be completed on a client following a cesarean section delivery? A: Assessing for nausea B: Last bowel movement before surgery C: Assessing for flatulence D: Tolerance of a full liquid diet

Misoprostol has been ordered for a pregnant patient at 41 weeks' gestation. Which statement made by the patient indicates to the nurse that teaching about the use of misoprostol has been effective? A: "Misoprostol enhances uteroplacental perfusion in an aging placenta." B: "Misoprostol increases amniotic fluid volume." C: "Misoprostol ripens the cervix in preparation for labor induction." D: "Misoprostol stimulates the amniotic membranes to rupture."

The nurse educator has just completed a lecture on intrauterine resuscitation. Which of the following definitions given by the new nurse graduates indicates the need for further teaching? A: Emergency cesarean section B: Placing internal monitors for a more accurate assessment of FHR and UCs C: Interventions that maximize maternal-fetal oxygenation D: CPR on the fetus while in utero

The nurse instructs the client on second stage positioning and pushing techniques. The nurse recognizes that the client understands the teaching when the client states: A: "Holding my breath helps increase pressure and push the baby out." B: "Having my legs in stirrups reduces the risk that I will tear." C: "Pushing on my side can increase blood flow to the baby." D: "I should begin pushing as soon as I am completely dilated."

The nurse is admitting a 16-year-old client for induction. She expresses fear about the pain of labor and delivery. which is the best response by the nurse? A: "Since you are under 18, your mom will decide what type of pain management is best for you." B: "You should get an epidural. You won't feel any labor, but pushing may be more difficult." C: "There are many options for pharmacological and non pharmacological pain relief. I'll discuss the pros and cons with you." D: "Childbirth classes are a great way to learn about pain relief options. Did you attend any?"

The nurse is caring for a client who is in the second stage of labor. The client's partner appears uncomfortable and unsure of what to do during the second stage of labor, while the client is highly emotional and exhausted. Which is the appropriate nursing response to the client's partner at this time? A: "Did you not take childbirth classes? B: "Do you want me to go get you a glass of water?" C: "Would you like me to show you how to assist your partner?" D: "Did you read your partner's birth plan?"

The nurse is caring for a patient who is a G4P3 at 38 weeks gestation, contracting every 3 minutes. Which assessment finding by the nurse requires immediate action? A: FHR of 105 per minute for the last 15 minutes B: Variable decelerations with 2 contractions C: Minimal variability D: Contraction duration of 60-70 seconds

The nurse is caring for a patient who is undergoing a term gestation pregnancy induction. Which is the nurse aware of regarding the induction of labor? A: It is achieved by external and internal version techniques. B: It is always done for medical indications. C: It is rated for probability of success by a Bishop score. D: It is only achieved through oxytocin infusion.

The nurse is caring for a term gestation pregnant patient who is desiring an external cephalic version (ECV). Which statement made by the patient would indicate that further education is required? A: "During this procedure, my provider will manually turn by baby vertex by manipulating my abdomen." B: "I will need a dose of Anti-D immune globulin since I do not plan to be induced in the next few days and my blood type is Rh-negative." C: "The ECV procedure will also help move my vasa previa out of the way so I can deliver vaginally." D: "You are going to place monitors on my belly to see if I am contracting, and I may need a dose of medication to stop my contractions if needed."

The nurse is caring for an obese patient and having difficulty maintaining the fetal heart rate (FHR) and contractions on an external fetal monitor (EFM). Which is the best action by the nurse in this situation? A: Notify the provider and document. B: Insert intrauterine pressure catheter (IUPC) and fetal spiral/scalp electrode (FSE). C: Reposition patient, adjust tocodynamometer and ultrasound transducer. D: Discontinue EFM and notify provider.

The nurse is caring for several patients requesting VBAC. Which patient would be the best candidate for a successful VBAC? A: A patient who had an emergency cesarean section because of fetal distress with a vertical incision. B: A patient who experienced arrest of dilation at 6 cm during her last pregnancy C: A patient who had a breech presentation in her last pregnancy currently has a cephalic presentation in this pregnancy D: A patient who experienced diabetes with a large for gestational age infant with her last and current pregnancy

The nurse is performing a sterile vaginal exam on a client to assess cervical readiness for induction via a Bishop score. Which component of the Bishop score is assessed by determining cervical thickness as indicated by the picture? A: Cervical position B: Dilation C: Effacement D: Station

The nurse is preparing a client for a cesarean section who is scheduled for 0900. What time will the nurse administer cefazolin? A: 07:30 B: 08:55 C: 08:00 D: 07:00

The nurse is preparing to administer a medication to a client who is reporting difficulty having a bowel movement following delivery of a healthy newborn boy by cesarean section. Which medication will the nurse administer? A: Hydrocodone B: Famotidine C: Docusate sodium D: Bisacodyl

The nurse is providing care to a woman at 38 weeks gestation. Which is a contraindication for labor induction? A: Post-term pregnancy B: Fetal demise C: Umbilical cord prolapse D: History of rapid labor

The nurse is providing education for a patient who has been diagnosed with a vasa previa at 34 weeks' gestation. Which statement would the nurse identify that teaching has not been effective? A: "At this point, I will need corticosteroids to mature my baby's lungs." B: "I will have to be admitted to the hospital for surveillance." C: "I still have the opportunity to labor and deliver my baby vaginally." D: "My provider will perform a pre-term cesarean birth at 35 weeks."

The nurse is receiving shift report on multiple patients. After receiving the report and comparing the patient histories, the nurse knows that which patient is most at risk for uterine rupture? A: This patient has had one lower transverse cesarean section, which is not a high risk for uterine rupture. B: A G3P2 whose youngest child is 3 years old and was born vaginally C: A G4P3 who has had three prior lower transverse cesarean sections and is pregnant with twins D: A G4P3 whose last baby was 7lbs 4 oz at term gestation

The nurse is scheduling a client for pre-operative blood work prior to a scheduled repeat cesarean section next week. The client is very concerned about needing more bloodwork drawn. How should the nurse respond to the client's concern? A: "The provider would order bloodwork even if you were having a vaginal delivery." B: "You need to get this done, or anesthesia will not allow for the surgery to occur." C: "The bloodwork helps the provider to identify potential risk factors that could complicate the surgery." D: "Just take your husband with you to help you stay calm while getting the blood drawn."

The nurse is scheduling a client for pre-operative blood work prior to a scheduled repeat cesarean section next week. The client is very concerned about needing more bloodwork. How does the nurse respond to the client's concern? A: "The provider would order bloodwork even if you were having a vaginal delivery." B: "You need to get this done or anesthesia will not allow for the surgery to occur." C: "The bloodwork helps the provider to identify potential risk factors that could complicate the surgery." D: "Just take your husband with you to help you stay calm while getting the blood drawn."

The nurse is teaching a client about the various pelvic shapes and the impact on vaginal birth. Which image would the nurse choose when discussing the most common pelvic shape? A: Android pelvis B: Anthropoid pelvis C: Gynecoid pelvis D: Platypelloid pelvis

The nurse is teaching a patient about the effects of smoking on fetal oxygen reserves. Which is the most appropriate statement in order to educate the patient? A: "Smoking is detrimental to you and your fetus, so we can help you stop." B: "Smoking causes you to have a small baby." C: "Smoking decreases the oxygen your baby receives. This may slow the baby's growth and cause an intolerance to labor." D: "We can prescribe a patch to help you stop smoking and increase the oxygen your baby receives."

The obstetric nurse is preparing a client for an epidural. What is the priority nursing intervention prior to this procedure? A: Monitor fetal heart tones B: Obtain maternal blood pressure C: Administer IV fluid bolus D: Assess for prior epidural anesthesia

The student nurse is watching the preceptor coach a client through the second stage of labor. During this stage, the nurse assesses the client for the urge to push and encourages the client to delay pushing until she feels the urge to. The student nurse recognizes this type of second-stage care as which? A: Directed pushing B: Spontaneous pushing C: Nondirected pushing D: Valsalva pushing

Upon entering a client room to perform the initial assessment following a cesarean section, the nurse finds the client tearful and the client's partner mentions mutual disappointment with the unexpected c-section delivery, as they had desired a natural birth. How does the nurse respond to the couple? A: "Since the baby is healthy, you should be happy." B: "C-sections happen all the time, there is nothing to cry about." C: "Tell me more about how you are feeling after the surgery." D: "Maybe next time you can delivery vaginally."

When an emergency cesarean section is required a guideline is set for a time frame surrounding the decision time to the incision time. The nurse explains to the client the guidelines for time to optimize fetal outcomes. What timeframe does the nurse share with the client? A: 60 minutes B: 45 minutes C: 30 minutes D: 15 minutes

While preparing for a cesarean section delivery, a client asks the nurse when she will be able to ambulate following the surgery. What information will the nurse share with the client? A: Three hours after the surgery B: After partial return of sensation C: After complete return of sensation D: Twenty-four hours after the surgery

With regard to a pregnant woman's anxiety about her labor experience, which does the nurse recognize? A: Anxiety may increase the perception of pain, but it does not affect the process of labor. B: Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity. C: Severe anxiety can increase pain and stress, which renders uterine contractions less effective. D: Continuous labor support decreases anxiety, but has no effect on pain perception or use of pain medication during labor.

Following a cesarean section, the nurse is preparing a client for skin-to-skin contact with the eight-hour old infant. What positioning will the nurse discuss with the client for an appropriate and safe skin-to-skin experience? Select all that apply. A: The infant can be placed prone on the mother's chest. B: The mother can be laying on her back in the bed. C: The mother can be sitting in a chair next to the bed. D: The infant can be placed with their face turned to the side. E: The mother can be sitting in semi-fowler's position in the bed.

C, D, E

While caring for a client, which interventions would the nurse include in the nursing care plan to provide culturally competent care? Select all that apply. A: Describe hospital protocols that will be followed during the delivery. B: Provide teaching on non-pharmacological pain management options as they are preferred by women of the client's culture. C: Identify who the woman prefers to care for her during labor and delivery. D: Provide the client's preferred foods as appropriate or encourage the client's family to bring foods from home. E: Determine who is the client's support person(s) and how they will participate in her care.

C, D, E

The nurse is in the room with a laboring patient who was found to have a prolapsed umbilical cord. The nurse will place the patient in which positions to help relieve pressure on the cord? Select all that apply. A: High-Fowlers B: Left lateral C: Knee-chest D: Squatting E: Trendelenburg

C, E

A client calls the nurses station to report that she thinks her water has broken. The nurse obtains supplies to assess the client. which would the nurse explain to the client prior to performing the vaginal exam? A: "The vaginal exam allows for the assessment of the fetal heart rate." B: "Laboring women often urinate and think it was the water breaking; let me check." C: "Your risk of infection has gone down now that the amniotic fluid has ruptured." D: "The lab test confirms that your amniotic fluid has ruptured."

A client requests to keep the placenta following delivery. How would the nurse respond to this request? A: "We do not allow that in this hospital. It is against all regulations." B: "Can you tell me what you plan to do with the placenta? We only allow this if you plan to bury the placenta." C: "Why would you want to take that home? It will begin to smell and can attract insects." D: "I understand that this is very important to you, and I will see what I can do to honor this request."

A full-term infant girl was born one minute ago. She is centrally pink with blue hands, her heart rate is noted at 148bpm, her arms and legs are flexed closely to her body, and she is crying vigorously. Using the table, calculate the Apgar score. A: 6 B: 7 C: 8 D: 9

A gravid patient at 41 weeks' gestation asks the clinic nurse about using complementary therapies to stimulate labor. Which is the best response by the nurse? A: "Herbal preparations like black cohosh are perfectly safe because they are natural." B: "Some couples have sex to stimulate labor, but that is not safe at this stage of pregnancy." C: "It is a myth that complementary therapies start labor." D: "Further research is needed to know if these methods are safe and effective. Let's talk with your provider about this."

A gravid patient in labor suddenly has dyspnea, hypotension, frothy sputum, and loss of consciousness. The nurse knows these are signs and symptoms of which obstetrical emergency? A: Placental abruption B: Uterine rupture C: Uterine inversion D: Amniotic fluid embolism

A gravid patient is having a trial of labor after cesarean (TOLAC). The nurse knows to watch for which obstetrical emergency? A: Dystocia B: Shoulder dystocia C: Amniotic fluid embolism D: Uterine rupture

A gravid patient is undergoing induction of labor with oxytocin. The nurse assesses the uterine contractions and notes that there are six contractions in 10 minutes, and the FHR is abnormal. Which is the priority nursing action? A: Administer oxygen via face mask. B: Notify the provider. C: Decrease the oxytocin dose. D: Discontinue oxytocin.

A new nurse is providing discharge instructions to a client who is going home three days after a cesarean section delivery. The charge nurse walks by the room and overhears the nurse giving the instructions. Which information would require intervention by the charge nurse? A: "You will want to continue pain medication as needed to manage the pain." B: "The baby will need to follow up with the pediatrician in a couple days." C: "You should try to rest when the baby is resting to help with recovery." D: "You can remove the staples at home tomorrow utilizing this staple remover."

A patient had spontaneous rupture of membranes and is in active labor with oxytocin augmentation. The FHR is presently 180 with no accelerations. Which is the priority nursing action for this patient? A: Notify the provider B: Administer an IV fluid bolus C: Discontinue oxytocin D: Assess maternal vital signs

A woman has been using nonpharmacological pain relief methods during labor, but now requests nalbuphine (Nubain). which finding would cause the nurse to hold the medication dose? A: Blood pressure 138/76 B: Moderate variability on the fetal heart tracing C: Client rating the pain 8/10 D: A history of prescription narcotic pain medication abuse

After delivery of the fetal head, the head retracts back into the maternal perineum. Which action would the nurse expect to be performed first? A: Apply pressure to the fundus. B: Deliver the posterior arm of the fetus. C: Prepare for emergency cesarean section. D: Flex the patient's thighs against the abdomen.

During the transition phase, the client states that she feels a strong urge to push. The nurse explains that which reflex triggers this urge? A: Deep tendon reflex B: Moro reflex C: Naegele's reflex D: Ferguson's reflex

Following a cesarean section, the nurse caring for the client notes the following assessment data: Temperature 99.1?, Heart rate 136, Respirations 20, Blood pressure 82/48, and skin pale and clammy to the touch. The nurse reports concern of what postpartum complication to the provider? A: Respiratory depression B: Renal failure C: Wound infection D: Postpartum hemorrhage

Following a vaginal exam on a client in labor, the nurse documents the client to be 8cm, 80%, +1. Which do these terms represent? A: Cervical effacement, fetal station, cervical dilation B: Cervical effacement, dilation, fetal station C: Fetal station, cervical dilation, cervical effacement D: Cervical dilation, effacement, fetal station

Following the occurrence of several cesarean sections, the charge nurse is reviewing the blood loss on four clients. What is the expected maximum value of blood loss for a client who underwent a cesarean section? A: 750 mL B: 825 mL C: 950 mL D: 1000 mL

Nurses in Labor and Delivery (L&D) participated in interprofessional unit-based drills and debriefings. Which strategy is critical to teamwork and communication according to the National Institute of Child Health and Human Development (NICHD)? A: Accurate interpretation of fetal monitoring tracings B: Mutual respect encouraged among disciplines C: Policies and procedures for each discipline to follow D: Standardize language for fetal heart rate definitions and patterns for all professional communications

Regarding oxytocin for labor induction, what is the most concerning side effect of oxytocin? A: Fetal heart rate baseline change from 140 to 130 beats per minute B: Increased blood pressure C: Oliguria D: Tachysystole

The OB nurse is assessing a patient utilizing structured intermittent auscultation (SIA). Which intervention assists the nurse in identifying fetal heart tones (FHT)? A: Perform a 20-minute Non-Stress Test (NST). B: Auscultate fetal heart tones (FHT) for at least 20 minutes. C: Auscultate FHT's during and after contractions for 30 seconds. D: Auscultate FHT's between contractions for at least 30 to 60 seconds.

The instructor explained how the fetus maintains acid-base balance during labor and discussed the process that occurs when available oxygen in the intervillous space falls below 50% of normal levels. Which response by the nurse indicates that the instructor would provide further teaching? A: "The fetus will convert from aerobic to anaerobic metabolism." B: "The fetal myocardium will change in oxygen consumption, which leads to changes in the FHR." C: "Redistribution of blood to vital organs occurs." D: "Lactic acid production increases and fetal growth accelerates."

The nurse caring for a multiparous patient in active labor suspects cephalopelvic disproportion (CPD). Which assessment finding supports this? A: Fetal station descending B: Large maternal stature C: Tachysystole D: Fetus not engaged in the pelvis

The nurse evaluates the tracing on a patient and notices 6 contractions in 10 minutes. Which assessment regarding the contraction pattern is priority? A: What is the intensity? B: What is the duration? C: What is the resting tone? D: What are possible causes?

The nurse in the Post Anesthesia Care Unit is weighing pads to calculate blood loss following a cesarean section delivery. The nurse converts the grams of weight to milliliters of blood loss. What is the conversion formula that is used in this calculation? A: 1 mL = 2 g B: 2 mL = 1 g C: 0.5 mL = 2 g D: 1 mL = 1 g

The nurse is assessing a client six hours post-operative cesarean section with intrathecal morphine administration. During the assessment, the nurse notes a respiratory rate of 10 breaths per minute for the client, and an increase in level of sedation, as well as vomiting. Which medication should the nurse first prepare to give the client? A: Metoclopramide B: Meperidine C: Oxytocin D: Naloxone

The nurse is assessing a low-risk pregnant client and documenting fetal heart tones every 5 minutes. which stage of labor is this client in, based on the frequency of assessments being performed? A: Latent phase B: Early phase C: First stage D: Second stage

The nurse is assessing a pregnant patient who is externally monitored and contracting every 3 to 4 minutes with each contraction lasting 40 to 60 seconds. The peak of the contraction reads 90 on the graph paper with a resting tone of 20. The patient rates her contractions as 10/10 and is crying. Which can the nurse document, based on these findings? A: The contractions are very strong, and the patient will probably deliver soon. B: The contractions are not adequate to make cervical changes. C: The resting tone is too high. D: The frequency and duration of contractions.

The nurse is assessing client 12 hours post cesarean section delivery, of a healthy male infant weighing 9 pounds 3 ounces. The client's Foley catheter was removed three hours ago. Which subjective assessment data requires immediate intervention? A: The client reports pain at a level of four and can tolerate a five. B: The client reports the infant nursed for about 20 minutes one and a half hours ago. C: The client has a blood pressure of 92/48. D: The client reports no voiding since the catheter was removed.

The nurse is caring for a patient in active labor. Assessment findings include: fetal heart rate (FHR) 125BPM, moderate variability, intermittent variable decelerations to the 100's and occasional accelerations, and the patient reports labor pain as 10/10. The nurse administers 50mcg of Fentanyl IV. Twenty minutes after administering the Fentanyl, the nurse notes FHR has been steady at 125 BPM, minimal variability, no decelerations and no accelerations. Which does the nurse assess related to these findings? A: Fetal hypoxia due to respiratory depression caused by administration Fentanyl B: Fetal Prematurity C: Utero-placental insufficiency D: Sedation caused by administration of Fentanyl

The nurse is caring for a term gestation laboring patient who just had a sudden onset of hypoxia and hypotension shortly after spontaneous rupture of membranes. Which is the nurse's priority action? A: Assist the patient into High-Fowler's position. B: Call the provider and prepare for imminent delivery. C: Draw a blood panel and prepare to administer blood products. D: Provide supplemental oxygen and left uterine displacement.

The nurse is preparing a client for a scheduled cesarean section for a breech presentation and a failed external cephalic version. The couple has two other children at home. What statement made by the client during the admission would require intervention by the nurse? A: "My mother is coming to stay with us for a couple weeks. She will be helping with housework." B: "I am disappointed with having to have a c-section, but am glad to finally meet my new son today." C "It is a relief to know my partner can stay in the room with me during the surgery." D: "I will miss being able to breastfeed. I breastfed my other children for one year each."

The nurse notes a fetal heart rate (FHR) deceleration that begins after the peak of the contraction and ends once the contraction is over. Which is the priority nursing action for this patient? A: Administer oxygen at 10L/min via nonrebreather face mask. B: Give an IV bolus. C: Discontinue oxytocin. D: Change the maternal position.

The nurse receives a call from the partner of a client in labor. The partner asks when they should come to the hospital. During which part of labor would a pregnant client be told to come to the hospital? A: Transition phase B: Fourth stage C: Second stage D: Active phase

The nursing instructor has just completed a lecture on fetal surveillance and the use of structured intermittent auscultation (SIA). The instructor knows that teaching was effective when the students recognize which contradiction to the use of SIA? A: 32-year-old G1, P0 patient at 40 weeks who is 6 cm dilated with a Category I tracing B: Presence of nurses and providers experienced in SIA C: Institutional policy addressing technique and frequency of SIA D: 26-year-old G4P3 at 39 weeks who is 3 cm dilated with a Category I tracing, being induced for gestational diabetes mellitus (GDM)

The patient is 38 weeks gestation and the nurse notes a decrease in the fetal heart rate (FHR) from 145 to 115 for a period of 15 minutes. How will the nurse document this finding? A: Prolonged deceleration B: Change in variability C: Fetal distress D: Change in baseline FHR

To improve fetal oxygenation and decrease maternal exhaustion during second stage labor, what would the nurse instruct the client to do? A: Take deep breaths from the nitrous oxide mask before pushing. B: Perform pant-blow breathing during the peak of a contraction. C: Use the Valsalva maneuver as the nurse directs pushing. D: Wait until there is a strong urge to push to begin bearing down efforts.

While caring for a pregnant client, which can the nurse provide to decrease fear and anxiety throughout labor and delivery? A: Ambulation B: Confidence C: Pain medication D: Labor support

While preparing a client for an emergency cesarean section, the nurse places an oxygen mask on the client. What is the rationale for this nursing intervention? A: Prevent hypertension B: Prevent tachypnea C: Decrease anxiety D: Fetal intolerance to labor

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