OB intrapartum (test #3) Nov 12

A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

1 and 3 are correct. 1. This is a sign of placental separation. 3. This is a sign of placental separation.

A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.

1, 5, 3, 4, 2. The correct order of the movements listed is: 1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1. Bulging perineum -indicates progression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor.

which of the following nonpharmacological interventions recommended by the nurse-midwife may help a client at full term go into labor? select all that apply 1. Engage in sexual intercourse 2. ingest evening primrose oil 3. perform yoga exercises 4. eat raw spinach 5. massage the breasts and nipples

1. Engage in sexual intercourse 2. ingest evening primrose oil 5. massage the breasts and nipples

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the doula to perform? Select all that apply. 1. Give the woman a back rub. 2. Assist the woman with her breathing. 3. Assess the fetal heart rate. 4. Check the woman's blood pressure. 5. Regulate the woman's intravenous.

1. Give the woman a back rub. 2. Assist the woman with her breathing.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1. Inform the mother that the rate is normal. This is the correct response. A fetal heart rate of 152 is normal.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

1. Left occipital anterior (LOA). The nurse's findings upon performing Leopold's maneuvers indicate that the fetus is in the left occiput anterior posi- tion (LOA)—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis.

In response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider ordered self-administered inhaled nitrous oxide. Which of the following common side effects should the nurse carefully monitor the client for? Select all that apply 1. Nausea 2. Hypotension 3. Dehydration 4. Lightheadedness 5. Late fetal heart decelerations

1. Nausea 4. Lightheadedness

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1. Provide caring labor support. The tracing is showing a normal fetal heart tracing. No intervention is needed.

A nurse is caring for women from four different countries. which of the women is most likely to request that her head be covered throughout her hospitalization? 1. Syrian woman 2. Chinese woman 3. Russian woman 4. Greek woman

1. Syrian woman muslim women who are from arabic countries are expected to keep their heads covered at all times

A nurse concludes that a woman is in the latent phase of labor. Which of the follow- ing signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.

1. Talking and laughing are characteristic behaviors of the latent phase.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to the posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions.

1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. The obstetric conjugate is the shortest anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucus plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 4. The client who says, "If I ever notice a greenish discharge from my vagina."

A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2cm. 2. 4cm. 3. 8cm. 4. 10 cm.

1. The nurse would expect the woman to be 2 cm dilated.

89 The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station −2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

1. Thin cervix

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

1. The relationship between the decelerations and the labor contractions will determine the type of deceleration pattern.

A pregnant woman is discussing positioning and the use of leg stirrups for delivery with a labor nurse. Which of the following client responses indicates that the client understood the information? Select all that apply. 1. When the client states, "I am glad that deliveries can take place in a variety of places, including a Jacuzzi bathtub." 2. When the client says, "I heard that for doctors to deliver babies safely, it is essential to have the mother's legs up in stirrups." 3. When the client states, "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees." 4. When the client says, "During difficult deliveries, it is sometimes necessary to put a woman's legs up in stirrups." 5. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position."

1. When the client states, "I am glad that deliveries can take place in a variety of places, including a Jacuzzi bathtub." 3. When the client states, "I understand that if the fetus needs to turn during labor, I may end up delivering the baby on my hands and knees." 4. When the client says, "During difficult deliveries, it is sometimes necessary to put a woman's legs up in stirrups." 5. When the client states, "I heard that midwives often deliver their patients either in the side-lying or squatting position."

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

1. after vaginal exams. 2. before giving analgesics. 3. periodically at the end of a contraction. 5. before the woman ambulates.

which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? select all that apply 1. assess fetal heart rate 2. infuse 1000 mL of ringer's lactate 3. place the woman in the Trendelenburg position 4. monitor blood pressure every 5 minutes for 15 minutes 5. have the woman empty her bladder

1. assess fetal heart rate 2. infuse 1000 mL of ringer's lactate 5. have the woman empty her bladder

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary health care practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.

1. fetal heart rate 2. contraction pattern 4. vital signs

A nurse is assisting an anesthesiologist who is inserting an epidural catheter. which of the following positions should the nurse assist the woman into? 1. fetal position 2. lithotomy position 3. Trendelenburg position 4. lateral recumbent position

1. fetal position

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1. weight gain 2. ethnicity and religion 3. age 5. gravidity and parity

On examination, it is noted that a full-term primipara in active labor is right occipi- to anterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. The descent is progressing well. 2. The fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1.The descent is progressing well. Descent is progressing well. The pre- senting part is 3 centimeters below the ischial spines.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

2 The client is exhibiting an expected behavior for labor. The woman is showing expected signs of the active phase of labor.

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

2. "You sound frightened." The nurse is using reflection to acknowledge the client's concerns.

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full- term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions. 2. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. 3. Baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. 4. Baseline of 140 to 142 with no obvious decelerations or accelerations.

2. A baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. These are related to head compression and are expected during the transition and second stage labor.

A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

2. A wedge should be placed under one side of the woman.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2. Evaluate the progress of labor. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

2. Evaluate the progress of labor. The woman's privacy should be main- tained while she is resting.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman on her side. 4. Check the fetal heart rate.

2. Have the woman breathe into a bag. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Her cervix has dilated from 2 to 4 cm. Once the cervix begins to dilate, a client is in true labor.

The nurse wishes to assess the variability of the fetal heart rate. Which of the follow- ing actions is recommended prior to performing this assessment? 1. Place the client in the lateral recumbent position. 2. Insert an internal fetal monitor electrode. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

2. Insert an internal fetal monitor electrode. Before the variability can be accurately assessed, an internal fetal heart elec- trode should be applied.

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consis- tent with this assessment? 1. LOA −1 station. 2. LSP −1 station. 3. LMP +1 station. 4. LSA +1 station.

2. LSP −1 station. The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left poste- rior (LP) and buttocks at -1 station are 1 cm above the ischial spines.

Between contractions, a client in the active phase of labor states, "Not only do these contraction really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting. too." The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor-relieving methods? 1. Epidural 2. Nitrous oxide 3. Narcotic analgesic 4. Spinal

2. Nitrous oxide

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Station is assessed by palpating the ischial spines.

An ultrasound report states, "The fetal head has entered the pelvic inlet." What does the nurse interpret this statement to mean? 1. The fetus has become engaged. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

2. The fetal head has entered the true pelvis. The inlet's boundaries are: the sacral promontory and the upper margins of the ilia, ischia, and the symphysis pubis. This is the entry into the true pelvis.

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

2. The woman is about to deliver the placenta These are signs of placental delivery

A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min × 30 sec. Fetal heart rate is in the 140s with good variabil- ity and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner? 1. The woman is high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

2. The woman is in early labor and could be sent home. There is no need for her to be hospitalized at this time.

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

2. The woman should be encouraged to grunt during contractions.

A G1 P0, 8 cm dilated, is to receive pain medication. The health care practitioner has decided to order an opiate analgesic with an analgesic-potentiating medication. Which of the following medications would the nurse expect to be ordered as the analgesic-potentiating medication? 1. Seconal (secobarbital). 2. Vistaril (hydroxyzine). 3. Benadryl (diphenhydramine). 4. Tylenol (acetaminophen).

2. Vistaril can be used as an analgesic potentiator.

77 Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

2. drop in blood pressure Hypotension is a very common side effect of regional anesthesia.

the practitioner is performing a fetal scalp stimulation test. which of the following fetal responses would the nurse expect to see? 1. spontaneous fetal movement 2. fetal heart acceleration 3. increase in fetal heart variability 4.resolution of late decelerations

2. fetal heart acceleration

A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

2. hypertension The blood pressure rises dramatically.

which of the following actions is appropriate for the nurse to perform when caring for a chinese-speaking woman in active labor? 1. apply heat to the womans back 2. inquire regarding the woman's pain level 3. make sure the woman's head is covered 4. accept the woman's loud verbalization

2. inquire regarding the woman's pain level

In addition to breathing with contractions, which of the following actions can help a woman in the first stage of labor to work with her pain? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2.Performing effleurage. Effleurage is a light massage that can soothe the mother during labor.

The physician writes the following order for a newly admitted client in labor: Begin a 1,000 mL IV of D5 1/2 NS at 150mL/hr. the IV tubing states that the drop factor is 10 gtt/mL. (calculate the drip rate to the nearest whole)

25 gtt/min

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

3. " I need ice chips because I am so hot." This comment is consistent with a woman in the transition phase of stage 1.

A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

3. "The baby is going to be born very soon. It is really too late for an epidural." Because this woman is a multipara, the position is LOA, and the station is +3, this is an accurate statement.

A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in the bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's health care practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Continue to provide encouragement during each contraction. 4. Place the client on her side with oxygen via a face mask.

3. Continue to provide encouragement during each contraction. Because this is a normal finding, the nurse should continue to provide labor support and encouragement.

58 A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

3. Decreased variability. Analgesics are central nervous system (CNS) depressants. The variability of the fetal heart rate, therefore, will be decreased.

On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is −2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via a face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

3. Delay pushing until the baby descends further and the mother has a strong urge to push. Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis to birth the baby.

Which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3. Knowledge learned at childbirth education classes helps to break the fear-tension-pain cycle. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle.

When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

3. Left lower quadrant. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

3. Muscle relaxation - is an integral part of Lamaze childbirth education. 4. Pelvic rocking - taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education.

The nurse is providing acupressure for pain relief to a woman in labor. Where is the best location for the accupressure to be applied? Select all that apply 1. On the malleolus of the wrist 2. Above the patella of the knee 3. On the medial aspect of the lower leg 4. At the top one-third of the sole of the foot 5. below the medial epicondyle of the elbow

3. On the medial aspect of the lower leg 4. At the top one-third of the sole of the foot

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3. The fetal lie is vertical. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

4. Monitoring for signs of rectal pressure.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal exams and blood tests. 2. Focusing the discussion on baby care rather than on labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment.

3. Utilizing visual aids like movies and posters during the classes. Using visual aids can help to foster learning in teens as well as adults.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist the mother with childbirth breathing. 2. Encourage the mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head.

52 During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

3. extension.

The nurse is caring for an Orthodox Jewish woman in labor. it would be appropriate to include which of the following in the plan of care? 1. encourage the father to hold his partner's hand during labor 2. Ask the woman if she would like to speak with her priest 3. provide the woman with a long-sleeved hospital gown. 4. place an order for the woman's postpartum vegetarian diet.

3. provide the woman with a long sleeved hospital gown.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

3."I took a shower about a half-hour ago. The contractions seem to hurt more since I finished." This response indicates that labor contractions are increasing in intensity.

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3.Fetal heart rate. It is essential to assess the fetal heart rate immediately after an amniotomy.

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

3.Occiput posterior. When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3.Right upper quadrant (RUQ). Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ.

The childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. push down with an open glottis 4. Do slow chest breathing.

3.push down with an open glottis Open glottal pushing is used during stage 2 of labor.

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing.

4 Encourage the woman to perform the next level breathing. This woman is in the active phase of labor. The first phase of breathing is probably no longer effective. Encourage her to shift to the next level of breathing is appropriate at this time.

It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4. "The contractions are about a minute long and I am unable to talk through them." This client is exhibiting clear signs of true labor. Not only are the contrac- tions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen.

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4. 10 cm dilated, 100% effaced, and +5 station. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus.

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold's maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4. A vaginal examination will provide the nurse with the best information about the status of labor.

A laboring woman and two men enter a labor suite. One of the men states "we and our surrogate are here for our baby's delivery. Where should we go?" Which of the following responses from the nurse would be appropriate. 1. Congratulate the surrogate on the gift she is giving the gay couple. 2. Remind the men that the labor and delivery experience is very stressful. 3. Remind the men that the woman is the baby's mother. 4. Ask the laboring woman whom she would like to be with her during labor.

4. Ask the laboring woman whom she would like to be with her during labor.

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

4. Contractions lasting 1 minute followed by a 120-second rest period. The frequency and duration of this contraction pattern are every three minutes lasting 60 seconds.

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Periodically during the peak of contractions. 4. For 1 minute immediately after contractions.

4. For 1 minute immediately after contractions. Intermittent auscultation should be performed for 1 full minute after contractions end.

To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into the squatting position 2. Advises the woman to push only when she feels the urge 3. Encourage's the woman to push slowly and steadily. 4. Massages the perineum with mineral oil

4. Massages the perineum with mineral oil

A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

4. Take a slow cleansing breath before bearing down. By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effective at this point in the contraction.

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."

4. The baby is almost crowning.

the nurse is interpreting the results of a fetal blood sampling test which of the following reports would the nurse expect to see? 1. oxygen saturation of 99% 2. Hgb of 11g/dL 3. serum glucose of 140 mg/dL 4. pH of 7.30

4. pH of 7.30

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. the fetus is becoming hypoxic 2. the fetus is becoming alkalotic 3. the fetus is in the middle of a sleep cycle 4. the fetus has a healthy nervous system

4. the fetus has a healthy nervous system

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

4.Scapula. A fetus in a scapular presentation is in a horizontal lie.

A nurse is teaching a class of pregnant couples the most therapeutic breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

4.Slow chest breathing. Most women find slow chest breathing effective during the latent phase.

47 A woman who is in active labor is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest.

4.The baby's chin is resting on his or her chest. the baby is in the flexed attitude.

During the third stage, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts firmly. 4. The uterine surface area dramatically decreases.

The order of change during the third stage of labor is: 3, 4, 1, 2.