OB2

Categorize the patient assessment findings

Findings that require intervention Persistent headache BP 144/94 Rupture of membranes Temperature 101.9 Findings that DO NOT require intervention Edema of the ankles & feet Striae Fetal heart rate 116

When performing teaching for a group of young women, which sexually transmitted infections should the nurse point out that can cause pelvic inflammatory disease (PID) and infertility if left untreated. Select all that apply.

Gonorrhea, Trichomoniasis, Chlamydia

0.36 ml

1) The nurse is caring for a newborn who is experiencing respiratory depression. The doctor ordered 0.36mg of Narcan to be given IM STAT. The concentration of medication is 1mg/ml. How many ml's should the nurse draw up to administer?

Betamethasone to mature the fetal lungs and increase surfactant production.

26) The nurse is caring for a woman who is 28 weeks pregnant and has been admitted in preterm labor. Which of the following medications will the nurse anticipate giving?

Avoid alcohol while taking the medication.

27) The nurse is caring for a patient who has just received a prescription for metronidazole to treat Trichomoniasis. What is a priority teaching point that the nurse will want to include for this patient while taking this medication?

• Internal fetal monitoring • Vacuum assisted delivery • Amniocentesis

28) A nurse is caring for a patient who is 32 weeks pregnant with her first child. Her prenatal lab work revealed that she is HIV positive. Which of the following orders/procedures from the physician would the nurse question? Select all that apply.

gestational hypertension

29) A patient at 22 weeks gestation presents to the clinic with a blood pressure of 144/96 without protein in the urine. Based on these symptoms, the patient is experiencing which condition?

To determine the presenting part, fetal lie and fetal attitude

30) The nurse is caring for a 30 year old G2 P1 mother who has come in for a labor check and has been determined to be in labor. The nurse will perform Leopold maneuvers for which purpose?

Assess the fetal heart rate

10) The nurse is caring for a patient who reports feeling a large "gush" of fluid coming from her vagina. Which of the following actions should the nurse take first?

Client priorities and preferences are incorporated into the plan.

11) The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?

The transition stage

12) A nurse is assisting with the care of a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits, and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing?

Late decelerations

13) The nurse is caring for a client suspected to have a placental abruption. The nurse predicts that the fetal monitor will exhibit which pattern if this is true?

Notify the registered nurse (RN) immediately

14) A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, which is the priority nursing action?

• "My amniotic membranes do not need to be ruptured." • "It is considered a non-invasive procedure." • It can determine the amount of amniotic fluid you have.

15) The nurse is reinforcing teaching about the benefits of internal fetal monitoring. Which of the following statements from the patient indicate the need for further teaching? Select all that apply.

"You will experience a surge of energy."

16) A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

To protect the infant from developing sepsis from the bacteria

17) Why is group B strep screening so important prior to delivery?

• Ensure that the bed is in the lowest position. • Make sure that the patient's call light is within reach • Provide education to the patient and her support person to call for help before ambulating.

18) The nurse has just administered a pain medication to a woman who is 4 hours post vaginal delivery. Which of the following interventions should the nurse perform to promote patient safety? Select all that apply.

The frequency of the contractions is consistent and the cervix is dilating and effacing

19) A woman who is 37 weeks pregnant presents to the OB unit for a labor evaluation. Which of the following assessment findings will lead the nurse to determine that this patient is in true labor?

"We will have to discuss this with the doctor, you will likely need a c-section."

2) A woman with a positive history of genital herpes is in active labor. The assessment reveals vesicles in the perineum area. Her membranes are ruptured, the cervix is dilated to 5 and she is 70% effaced. The mother has expressed her desire for an un-medicated vaginal delivery. Which of the following responses from the nurse is appropriate?

A large for gestational age baby

20) The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out that which situation can potentially occur during pregnancy?

The client complains of a headache and blurred vision.

21) The nurse is monitoring a cient with mild gestational hypertension (GH). Which data indicate that GH is a concern?

Prepare to administer an IV fluid bolus to manage maternal hypotension and fetal bradycardia.

22) The nurse is assisting in the care of a woman who is 39 weeks gestation, and is currently dilated to 5cm and 70% effaced. She has requested an epidural for pain management. Which of the following is a priority nursing intervention for the nurse to complete when caring for patient receiving an epidural?

urine ketones present

23) A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition?

call for assistance

24) A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside of the client's vagina. Which of the following actions should the nurse perform first?

Umbilical cord compression

25) A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

Dizziness

3) A nurse is assisting in the care of a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations?

Average baseline fetal heart rate of 90 beats per minute Late decelerations occurring with each contraction

4) The nurse is caring for a woman who is in active labor. She is dilated to 8 and the cervix is 100% effaced. Which of the following findings require intervention from the nurse? Select all that apply.

calcium gluconate

5) The nurse is caring for a patient who is receiving magnesium sulfate for severe pre-eclampsia. See the nurses note and flowsheet below: What medication should the nurse prepare to administer?

The normal fetal heart rate is 110-160

6) The nurse is teaching a group of students about fetal monitoring. Which response from the student indicates an understanding about fetal heart rate monitoring?

•Birth of the baby occurs in the second stage. •Women are talkative and in good spirits during the latent phase. •During the transition phase women become irritable and unsure and need support and encouragement.

7) The nurse is providing education for a group of students about the stages of labor. Which of the following responses from the students indicates an accurate understanding? Select all that apply.

0.13 mL

8) The physician has ordered 0.25mg of terbutaline sub-q to be given to a woman in preterm labor. The concentration is 2mg/ml. How many ml's will you draw up to administer?

Continue to monitor the patient.

9) The nurse is caring for a woman in labor. The picture below represents the fetal heart rate tracing. What is the nurse's priority action?