Passpoint - Intrapartum Period
A client concerned about the pinkish "stretch marks" on her abdomen asks the nurse about them. Which response by the nurse would be most appropriate?
"Although they will fade, they won't disappear."
Vaginal examination of a client in labor reveals that the biparietal diameter of the fetal head has reached the level of the ischial spines. The nurse would interpret this as indicating which fetal station?
0
Which action should the nurse perform if the client's blood pressure falls during the first or second stage of labor?
Administer oxygen through a face mask at 6 to 10 L/minute.
When assessing the fetal heart rate tracing of a client in labor, the nurse assesses the fetal heart rate at 170 beats/minute. What should the nurse do first?
Administer oxygen to the client.
Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
An increased sense of rectal pressure
An RN and LPN are caring for a client who is about to undergo vacuum extraction for ineffective pushing. Which of the following nursing actions should be assigned to the LPN?
Catheterizing the client before the procedure
A client tells a nurse that her contractions began 6 hours ago. When the nurse is collecting data, which finding would confirm that the client is in true labor?
cervix that is 100% effaced and 2 cm dilated
The nurse is performing Leopold's maneuvers to determine fetal presentation and position. Which illustration shows the third maneuver?
*** To perform the third maneuver, the nurse gently grasps the lower portion of the abdomen just above the symphysis pubis between the thumb and index finger and presses them together to determine any movement and whether the part is firm or soft. This maneuver determines the part of the fetus at the inlet and its mobility. Option 1 shows the fourth maneuver of locating the fetal brow; option 3 shows the first maneuver of palpating the upper abdomen to determine the size, shape, and mobility of the fetus; and option 4 shows the second maneuver of determining the location of the fetal back.
A client in labor has been given an epidural anesthetic. When collecting data on the client immediately following the epidural administration, which finding would be most important for the nurse to report?
Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.
A nurse is observing a fetal monitoring strip to time the contractions of a client in labor. Identify the beginning of the contraction in the illustration shown.
*** 2nd row, 10th column starting at 0
A nurse is assisting in the delivery room. The health care provider prepares to perform a midline episiotomy. On the illustration below, identify the area where the health care provider will place the incision and the nurse will assess healing status.
*** An X is placed in the center of the perineum for a midline episiotomy. An episiotomy is a surgical enlargement of the vaginal opening that allows easier birth of the fetus and prevents tearing of the perineum. The incision is made in the perineum and can be midline or right or left mediolateral.
The nurse is assisting with the birth of a fetus in a frank breech presentation. Which image illustrates this position?
*** In a frank breech presentation, the buttocks are the presenting part, with the hips flexed and the knees remaining straight. In a complete breech (option A), the knees and hips are flexed. In a footling breech (option B), neither the hips nor the lower legs are flexed, and one or both feet may present. In an incomplete breech (option D), one or both hips remain extended, and one or both feet or knees lie below the breech.
A client in labor is 8 cm dilated. The fetus, which is in vertex presentation, is 75% effaced and at 0 station. In the illustration shown, identify the level of the fetus's head.
*** Station refers to the level of the presenting part in relation to the pelvic inlet and the ischial spines. A 0 station indicates that the presenting part lies at the level of the ischial spines. Other stations are defined by their distance in centimeters above or below the ischial spines.
A client in the second stage of labor experiences membrane rupture. Which intervention by the nurse is appropriate?
Check for a prolapsed cord.
The nurse is caring for a client in labor and notes that the fetal heart rate (FHR) slows to 100 beats per minute (bpm) during contractions and increases to 120 when the uterus relaxes. The nurse would take which appropriate intervention?
Continue to monitor and document
A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?
Fetal heart rate variability within an acceptable range
A nurse is caring for a client who has just delivered a neonate, and finds that the fundus is boggy and deviated to the right. Which action taken by the nurse helps with uterine involution?
Have the client void.
A client in the early stages of labor who is admitted to the labor and delivery unit is noted to have not recently bathed or changed her clothes. Which action should the nurse take to help this client?
Help the client to undress and suggest a quick bath to freshen up.
A client with moderate pregnancy-induced hypertension (PIH) received regional anesthesia during labor and delivery. One hour after administration of the regional anesthesia, what should the nurse monitor the client for?
Hypotension
A client in the early stage of labor states that she has a thick, yellow discharge from both of her breasts. Which action by the nurse is most appropriate?
Informing the client that the discharge is colostrum, which is a normal finding
The nurse is caring for a primigravid client in the labor and delivery area who developed disseminated intravascular coagulation (DIC) due to abrupt placenta. Which intervention should the nurse expect the health care provider to implement first?
Infusion of heparin drip
The nurse caring for a primipara in late first stage of labor notes left occipito-anterior (LOA) position, 7 cm dilated, and at +2 station. Which finding should be reported to the health care provider?
Labor is progressing well.
The nurse is monitoring a primigravid client in labor who received epidural anesthesia. Which action(s) taken by the nurse will help prevent adverse effects of the spinal anesthesia? Select all that apply.
Maintain hydration. Assist the client to a left lateral position. Monitor vital signs.
Which intervention should be included in the safety plan for the maternal- infant unit?
Making sure that the spouse or significant other wears an identification band
A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next?
Massage the fundus.
When checking a client 1 hour after vaginal delivery, the nurse notes blood gushing from the vagina, pallor, and a rapid, thready pulse. Which actions should the nurse take? Select all that apply.
Massage the fundus. Notify the health care provider. Obtain vital signs. Obtain a blood sample for a complete blood count.
A client is admitted to the labor and birth unit in active labor. She has had no prenatal care but appears to be between 32 and 35 weeks' gestation. Her history reveals that she is gravida 5, para 1. She tells the nurse that she thinks her friend gave her a cigarette containing crack cocaine. Which actions would be most appropriate for the nurse to do next? Select all that apply.
Move the precipitant birth cart to the labor room. Notify the neonatologist on call.
A client is to have an epidural block to relieve labor pain. Her blood pressure is noted to be 90/60 mmHg. What should the nurse do?
Notify the anesthesiologist.
A primigravida client who has been in labor for 13 hours clenches her fists, tightens her muscles, and screams during every contraction. Her reaction to labor seems exaggerated compared with the contraction pattern recording from the electronic fetal monitor (EFM). Which intervention would be most important?
Palpate the client's abdomen to determine the intensity of labor contractions as they are taking place.
When caring for a client who's having her second baby, the nurse suspects cephalopelvic disproportion. Which action should the nurse take?
Prepare for a cesarean birth.
A client in the active phase of labor has a reactive fetal monitor strip and has been encouraged to walk. When the client's membranes ruputer and the fetal cord is observed in the vaginal canal, what is the priority action by the nurse?
Put the client in a knee-chest position.
The nurse places a client in labor in a supine position to obtain a good monitor tracing when suddenly, the client becomes light-headed and diaphoretic. Which of the following should be the nurse's first action?
Reposition the client to her left side.
A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take?
Reposition the client to left lateral position.
A client is in the first stage of labor. Her cervical dilation has progressed from 4 to 7 cm. The nurse understands that the client is most likely in which phase?
active phase
A nurse is caring for a client in labor diagnosed with active genital herpes. Which actions should the nurse anticipate? Select all that apply.
cesarean birth witness consent for surgery
A client at 42 weeks' gestation is 3 cm dilated and 30% effaced with membranes intact and the fetus at +2 station. Fetal heart rate (FHR) is 140 to 150 beats/minute. After 2 hours, the nurse notes on the external fetal monitor that for the past 10 minutes, the FHR ranged from 160 to 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. The nurse suspects fetal hypoxia based on which finding?
excessive fetal activity and fetal tachycardia
A nurse is assisting in monitoring a client in labor. Which data obtained by the nurse is indicative of fetal well-being?
fetal heart rate of 145 to 155 beats/minute with 15-second accelerations to 160
A client in labor is scheduled to receive epidural analgesia. In preparation for this procedure, which action would be most important for the nurse to do?
giving a fluid bolus of 500 mL
A nurse is assisting in monitoring a client who's receiving oxytocin to induce labor. The nurse would be alert for which maternal adverse reactions? Select all that apply.
hypertension fluid overload uterine tetany
During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by:
massaging and supporting the perineum.
A pregnant client at term is in the first stage of labor and has an electronic fetal monitoring (EFM) device in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion?
moderate variability
A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?
postpartum hemorrhage
A client is receiving a tocolytic agent to help stop preterm labor contractions. The nurse would be alert for signs and symptoms of which potentially life-threatening complication?
pulmonary edema
A nurse is providing care to a client in labor and reviewing the plan of care. The nurse determines that the client has understood the information when the client states that she wil begin pushing during which stage of labor?
second stage of labor
A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used.
strong Braxton Hicks contractions acme decrement relaxation
A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?
Ask the client about her most recent blood glucose levels.
When caring for a client during the second stage of labor, which action would be most appropriate?
Assisting the mother with pushing
A client who's being admitted to labor and delivery has the following data collection findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which would be the priority at this time?
Preparing for immediate delivery
A primigravida client with severe gestational hypertension is admitted to the labor unit. She has been receiving magnesium sulfate IV for 3 hours. The latest data reveals deep tendon reflexes (DTRs) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and urine output of 20 mL/ hour. Which action would be most appropriate?
Stop the magnesium sulfate infusion.
A woman is in the third stage of labor after having just given birth to a healthy newborn. Which actions would be most important during this stage? Select all that apply.
assisting with skin-to-skin contact of the mother with the newborn encouraging the woman to breast-feed if appropriate assisting the woman into a comfortable position
A client in labor is receiving magnesium sulfate as an intravenous infusion. Which medication should the nurse ensure is at the bedside while the magnesium sulfate is being infused?
calcium gluconate
The nurse is caring for a 28-year-old primavida who is reporting severe back labor. Which nursing intervention is most effective in improving the comfort of the client?
Back massage with sacral pressure
The nurse-midwife determines that a client is in the second stage of labor and the presenting part is descending rapidly. What action should the nurse take to prevent complications?
Encourage the client to practice breathing exercises to decrease the urge to push.
The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.
A client has received dinoprostone to help ripen her cervix. What should the nurse do to determine effectiveness of the drug?
Assess for ripening and softening of the cervix.
A client with a full-term, uncomplicated pregnancy comes into the labor and delivery unit in early labor states, "I think my water has broken." Which action by the nurse would be the priority?
Note the color, amount, and odor of the fluid.
A nurse mentor assists a novice nurse in positioning a laboring client to the hands/knees position. After delivery, the novice nurse asked why was the client put into this position. Which rationale would the mentor provide for repositioning the client?
"The health care provider noted the prolapsed cord."
A client in the early stages of labor asks the nurse whether it's really necessary for her to purchase a car seat, noting that they're very expensive. Which response by the nurse is best?
"The only way to safely transport your baby in a car is to have him restrained securely in a car seat."
The nurse is preparing to admit a client who came to the delivery area in the company of her husband. The client states, "I am in labor and I attended the facility clinic for prenatal care." Which question should the nurse ask her first?
"What is your expected due date?"
A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has an intravenous infusion of oxytocin running. Which response by the nurse would be best?
"You may use the bathroom with my assistance."
A health care provider has ordered an IV of 5% dextrose in lactated Ringer's solution at 125 mL/hour. The IV tubing delivers 10 drops per mL. How many drops per minute should fall into the drip chamber?
20 to 21
A client in labor is prescribed an IV of 5% dextrose in lactated Ringer's solution to run at 125 mL/hour. The IV tubing delivers 10 drops per mL. At which infusion rate should the nurse set the IV? Record your answer using a whole number.
21
The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN?
A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.
The nurse is checking the fetal heart rate (FHR) of a client admitted to the labor and delivery area and notes an FHR of 144 beats per minute associated with a 10 beats per minute short-term variability. Which of the following action should the nurse take?
Continue to monitor the client
A 32-year-old multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Which action taken by nurse promotes pain relief in the laboring client?
Direct pressure and massage to the sacral area
A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings?
A vaginal laceration
A client who's in active labor is yelling, "Get out of here!" As the nurse enters the client's room, she notices the client's estranged husband in the room. How should the nurse intervene?
Ask the husband to leave or phone security.
During the active phase of the first stage of labor, a client undergoes an amniotomy. Which action should the nurse take to prevent complications? Select all that apply.
Assess for cord prolapse postprocedure. Monitor fetal heart rate. Reposition the client to the left side. Monitor blood pressure.
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?
Contractions will be stronger and more uncomfortable and will peak more abruptly.
Which care intervention is appropriate for the fourth stage of labor?
Assessing lochia and the location and consistency of the fundus
A primigravid client is admitted to the labor and delivery area in the early first stage of labor. She is breathing with each contraction. Which action taken by the nurse helps the client deal with the pain of labor?
Assist the client in performing effleurage.
A client in labor receives epidural anesthesia. Which nursing action should the nurse take?
Assist with positioning the client.
A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best?
Assisting the client to ambulate in the room
What is the next priority nursing action after establishing an airway for a neonate?
Drying the neonate to stabilize the neonate's temperature
A client is progressing through the first stage of labor and is now having a strong urge to push. What should the nurse do next?
Encourage grunting with each contraction.
The nurse is caring for a client in the third stage of labor following a vaginal delivery. The nurse observes blood gushing from the client's vagina, umbilical cord lengthening, and a globular-shaped uterus. Which of the following actions should the nurse take?
Encourage the client to push.
Which action should the nurse take to promote the descent of the fetus's presenting part?
Encourage the client to void every 2 hours.
A client who is induced at 40 weeks' gestation with oxytocin drip is expressing fear and anxiety about the induced labor. Which interventions should the nurse implement? Select all that apply.
Establish trust with the client. Explore the client's coping behaviors. Keep client informed about progress and procedures.
A multiparous client in labor is 5 cm dilated and requesting pain medication. The nurse administered an opioid analgesia. After 15 minutes, the client expresses the urge to bear down. What should the nurse do first?
Perform vaginal examination to determine cervical dilatation.
While cervical dilation and effacement are being evaluated in a client in labor, a prolapsed cord is discovered. Which intervention would be most important? Select all that apply.
Position the client in Trendelenburg position. Prepare the client for an emergency cesarean section. Monitor fetal heart rate.
Which of the following health conditions makes it necessary for the nurse to check blood pressure frequently during labor?
Preeclampsia
Vaginal examination of a client in labor reveals the fetus's larger, diamond-shaped fontanel is toward the anterior portion of the client's pelvis. The nurse interprets this finding as indicative of what situation?
The client may need interventions to ease her back labor and change the fetal position.
A nurse is caring for a pregnant client who is scheduled to undergo an amniotomy to induce labor. After the procedure, which client goal should take the highest priority?
The fetus will maintain adequate tissue perfusion.
A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony?
Massage the fundus.
A client is admitted to the labor and delivery area. How can the nurse most effectively determine the effectiveness of the contractions?
Progressive cervical dilatation and descent from station +4 to 0
A client in labor, who attended natural birth classes, is asking for something to relieve the pain. What is the most appropriate action for the nurse to take?
Contact the health care provider, supporting the client until an analgesic is prescribed.
A 23-year-old primigravida client is in the active stage of labor. She and her husband have been using breathing techniques. The husband asks whether he can do anything more to help his wife during labor. What should the nurse suggest?
Provide helpful distractions.
A client comes to the labor unit reporting contractions. After gathering data, it is determined the client is having Braxton Hicks contractions, and education regarding the difference between true and false labor is given. Which statement by the client indicates the teaching has been effective?
"Braxton Hicks contractions begin in the abdomen and remain irregular."
A client in active labor has severe second-degree burns on her buttocks. When questioned about the burns, the client replies, "I was trying to use that hot water thing to help my hemorrhoids." Which statement made by the nurse is therapeutic?
"Did I hear you say you sustained this burns from hot water application to the buttocks?"
The nurse is completing the admission assessment of a client in the labor and delivery area, when the client and her husband ask whether their sons, ages 8 and 10, can witness the childbirth. Which statement made by the nurse is accurate?
"Each child attending the childbirth should have a separate support person."
The health care provider has just performed a vaginal examination on a client and tells the nurse that the fetus is in a left occiput anterior position. Which graphic illustrates that position?
*** The first graphic (A) illustrates that in a left occiput anterior position the fetal occiput is facing the left and anterior quadrant of the maternal pelvis. The second graphic (B) illustrates that in a left occiput transverse position, the fetal occiput is facing the left quadrant and is transverse. The third graphic (C) illustrates that in the right occiput anterior position the fetal occiput is facing the right and anterior quadrant of the maternal pelvis. The fourth graphic (D) illustrates that in the left occiput posterior position fetal occiput is facing the left and posterior quadrant of the maternal pelvis.
A pregnant client is at term and in labor. The nurse is checking the fetal heart rate. Which finding would the nurse interpret as indicating appropriate fetal perfusion?
135 beats/minute
A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?
42 drops/minute
A nurse is collecting data from a client in labor and suspects that the client may have been physically abused by her male partner. Which intervention by the nurse would be most appropriate?
Collaborate with the health care provider to make a referral to social services.
A pregnant client with a history of cardiac dysfunction has been taking propranolol, a beta-adrenergic blocker, to treat hypertension. During labor, the nurse should stay alert for which adverse effect of this drug?
Uterine hypertonus
A nurse tells a client in labor, "If I were you, I'd ask the doctor for something for pain; you shouldn't have to suffer during labor." Which ethical principle is the nurse promoting?
Autonomy
A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in the fetal heart rate (FHR). After notifying the registered nurse in charge, what should the nurse do next?
Change the client's position.
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
Change the client's position.
A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.
Check vital signs. Check the fundal height. Notify the RN.
A nurse is caring for a primigravida client who is in labor. When does the nurse suspect the client has progressed to the second stage of labor?
Client has an uncontrollable urge to bear down.
A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be effective for the couple at this time?
Instruct the husband on touch, massage, and breathing patterns.
The licensed practical nurse (LPN) is co-assigned with the registered nurse to provide care for a client receiving oxytocin to induce labor. When discussing adverse side effects of oxytocin, which conditions should the LPN notify the registered nurse of immediately? Select all that apply.
Fluid overload with crackles in the lung fields. A blood pressure of 170/92 mm Hg. Palpable uterine tetany.
Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which concerns?
Headache, blurred vision, and facial and extremity swelling
A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be most appropriate?
Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy.
A diabetic client in labor tells the nurse she has been feeling nauseous since her labor started and did not take her insulin even after eating some soup and crackers. One hour later, she reports increased nausea and feeling flushed. The nurse notes a fruity odor to her breath. What do these findings suggest?
Diabetic ketoacidosis
A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response?
Explain to the client that the feeling is normal during this stage.
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should take which of the following actions?
Notify the obstetrician
A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene?
Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What should the nurse do next?
Prepare for immediate delivery of the baby
A gravida 1 para 0 (G1P0) client is admitted in labor with a fetal heart rate of 185 and meconium-stained amniotic fluid. The obstetrician has recommended cesarean birth. Which preoperative nursing interventions should the nurse initiate immediately? Select all that apply.
Shave the abdomen. Obtain consent. Obtain blood for type and cross match. Wash perineal area with antiseptic solution.
The nurse is assisting in the delivery of a client with precipitate labor. After the delivery of the head, which actions should the nurse take to ensure safety of the mother and baby? Select all that apply.
Suction infant's mouth then nose with bulb syringe. Check around neck for possible tight umbilical cord. Support perineum with a sterile towel as the head is crowning.
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first?
The time of membrane rupture
A nurse is reviewing data for multiple clients in the first stage of labor. Which client should receive priority attention?
a client with blood pressure of 160/90, pulse 92, respiration 22, temperature 99.1, and positive proteinuria
A nurse is collecting data on a client who is in preterm labor. Which finding related to the fetal heart rate indicates fetal distress?
baseline rate of 100 beats/minute
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at
blood pressure of 146/94 mm Hg
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress?
blood pressure of 146/94 mm Hg
A pregnant client is admitted to the labor unit in early labor. When reviewing the plan of care for the client, which laboratory test would the nurse identify as being critical to obtain?
blood type
A nurse identifies meconium in the amniotic fluid of a pregnant client in labor who has had a spontaneous rupture of membranes. The nurse identifies this finding as normal because of which situation?
breech presentation
A multiparous client admitted to the labor unit has not received prenatal care for this pregnancy. When collecting information from this client, which data would be most important to obtain?
date of last menstrual period (LMP)
A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding?
fetal heart rate of 80 beats/minute
A nurse is participating in developing the plan of care for a client in labor. When reviewing the collected data, which finding would the nurse identify as requiring additional action?
increase in blood pressure to 154/96 mm Hg during contractions
A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered?
lateral
A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown), into which position should the nurse assist the client?
left lateral
A gravida 3 client reveals that she gave birth to her first child vaginally and her second child by cesarean birth due to a complete placenta previa. The client agrees to attempt a vaginal birth after cesarean (VBAC) and presents at the local hospital in early labor, 3 to 4 cm dilated, 80% effaced, and at +1 station. The nurse anticipates the possibility of VBAC based on which type of incision noted in the record?
lower uterine segment transverse incision
A pregnant client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. The client has a history of hypertension during pregnancy. The nurse anticipates the administration of which medication?
magnesium sulfate
The nurse instructs a client in labor to change position frequently to promote comfort and prevent complications. Which complication is likely to occur with the client in supine position? Select all that apply.
maternal hypotension fetal hypoxia
A client has given birth vaginally several minutes ago. The nurse notes blood gushing from the vagina, the umbilical cord lengthening, and a globe-shaped uterus. The nurse should monitor the client closely for which condition?
placental separation
The nurse is reviewing information about the stages of labor with a pregnant client. The nurse determines that the client has understood the information when stating that crowning occurs during which stage of labor?
second
A nurse is caring for a client in labor whose cervix is 8 cm dilated. The client's contractions are occurring every 2 minutes. She is irritable and in considerable pain. What type of breathing should the nurse encourage the client to use during the peak of a contraction?
shallow chest breathing
A client is admitted to the labor unit in early labor. The nurse would encourage the client to assume which position to promote tissue perfusion?
side-lying
A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response?
stimulates labor and prevents hemorrhage
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for:
uterine atony.
