quiz4- labor & delivery
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 consistent with this assessment? 1. LSP and -1 station 2. LOP and -1 station 3. LMP and +1 station 4. LSP and +1 station
1. LSP and -1 station
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.
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. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question.
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. Vaginal examination.
Which of the following vaginal examination results demonstrate that the fetus is engaged? (Select all that apply) A. 4 cm 80% 0 B. 9 cm 100% -2 C. 6cm 90% +1 D. 2cm 90% +1 E. 8cm 90% -1
A. 4 cm 80% 0 C. 6cm 90% +1 D. 2cm 90% +1
A woman had a baby by normal spontaneous vaginal delivery a few minutes ago. The nurse notes that a gush of blood was just expelled from the vagina, the umbilical cord lengthened, and the fundus has risen in the abdomen. What should the nurse conclude? A. The woman has an internal laceration B. The woman is about to deliver the placenta C. The woman has uterine atony D. The woman is about to deliver a second baby
B. The woman is about to deliver the placenta
Through vaginal examination, the nurse determines that a woman is 6cm dilated and 100% effaced with the fetus at a 0 station. The nurse reports this as: A. First stage, latent phase B. First stage, transition phase C. First stage, active phase D. Second stage, latent phase
C. First stage, active phase
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? A. The baby's chin is resting on its chest B. The baby's presenting part is engaged C. The baby is in the horizontal lie D. The baby is in a breech position
A. The baby's chin is resting on its chest
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 first based on this assessment? A. Encourage the woman to push B. Assess bladder C. Move the client into a supine position with legs in stirrups D. Provide firm fundal pressure
B. Assess bladder
Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? A. Severe headache B. Hypotension C. Increase in bladder retention D. Fetal heart accelerations
B. Hypotension
A patient that had a cesarean section two days ago has been diagnosed with a post-dural puncture headache. The nurse understands that the following interventions should be implemented (Select all that apply). A. Decrease fluid intake B. Increase caffeine intake C. Place patient in a semi-fowlers position D. Encourage bedrest in a quiet and dimly lit room E. Administer oral analgesics for the pain
B. Increase caffeine intake D. Encourage bedrest in a quiet and dimly lit room E. Administer oral analgesics for the pain
While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundus, a long flat object on the mother's left side, small irregular objects on the mother's right side, and a soft round mass above the symphysis. Which of the following positions is consistent with these findings? A. ROA B. LSA C. LSP D. ROP
B. LSA
A patient who just entered the recovery room after a cesarean section is requesting pain medication. The nurse understands that nalbuphine (Nubain) is contraindicated for this patient after noting the following: A. The patient has a history of malignant hyperthermia in her family history. B. The patient is opiate dependent. C. The patient has already received morphine in her spinal anesthesia. D. The patient has a history of vomiting with this medication.
B. The patient is opiate dependent.
During a vaginal examination, the nurse determines that the patient is in a LOP position. The best non-pharmacological intervention that can be done with this patient to relieve her pain is: A. Have her perform effleurage during contractions B. Allow her to labor in a tub of warm water C. Use aromatherapy in the room and play soothing music D. Have her labor in the hands/knee position
D. Have her labor in the hands/knee position
The nurse is assessing a client who states "I think I am in labor." Which of the following findings would positively confirm the client's belief? A. She is contracting every 2 minutes B. Her membranes have ruptured C. The fetal head is engaged D. Her cervix has dilated from 2 to 4 cm.
D. Her cervix has dilated from 2 to 4 cm.
