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a client comes to the hospital at 38 wks gestation thinking she is in labor, but after several hours of observation she is sent home. The client asks how she can tell the difference between true labor and false labor. Which of the following should the nurse indicate will occur in true labor?
contractions increase in intensity and duration
What is the immediate concern when a client’s membranes rupture spont. prior to fetal engagement?
prolapsed umbilical cord
to what does the term fetal presentation refer?
the part of the fetus that enters the pelvis first
When a fetus presenting as a breech has both legs extended so that the feet are near the face, the nurse would expect to find which type of breech?
Which client position is preferred during the active and transition phases of labor because it promotes uteroplacental blood flow?
the nurse monitors the frequency of contractions timed:
from the beginning of one contraction to the beginning of the next
What is the significance of crowing?
birth is imminent
immediately after the rupture of membranes (either spont. or artificially) it is most important for the nurse to:
assess the FHR for a full minute, and report significant changes
shortly after the clients health care provider evaluated her cervical dilation as being 7 cm, she tells you, “I think I’m about to have the baby!” which of these actions should the nurse take immediately?*
visualize her perineum for crowning
a labor client who is 8 cm dilated suddenly starts to shake her arms and legs, and then vomits. she says “I can t take it! give me something for the pain!” What action should the nurse take?
* explain that these reactions are normal during the transition phase
When are labor clients urges to bear down?
* with each contraction as soon as the cervix is completely dilated
when assisting a labor client with her breathing techniques, the nurse knows the client will use which of these breathing methods during the transition phase of labor?
10 minutes after the cutting of the baby’s umbilical cord, the nurse observes a sudden gush of blood, a lengthening of the cord at the vaginal orifice, and that the uterus has assumed a more globular shape. These signs are most indicative of-
14) shortly after delivery a client experiences a shaking chill. what is the nurse’s most appropriate action?-
cover her with a warmed blanket
15) clients in labor are encouraged to walk in which of these circumstances?-
when the membranes are intact
16) which of these is considered to be a danger sign that may occur during labor?
- maternal temp above 100.4F
17) while awaiting the health care provider’s arrival in a precipitate birth, which of these actions should the nurse take first?
- check of the presence of a nuchal cord
18) When a prolapsed cord is identified, which of these nursing actions assumes priority?
- insert 2 fingers of a sterile gloved hand into the vagina, and put pressure on the presenting part to lift off the cord.
19) when caring for a client receiving a secondary oxytocin infusion to induce or augment labor, the nurse would NOT discontinue the oxytocin in which of these situations?
-when the contractions are of 40 to 60 seconds duration
20) When an emergency cesarean birth is necessary, it is MOST important for the nurse to:-
review with the client the events that necessitated this type of delivery
21) the nurse asses a newborn infant at 1 and 5 minutes using the APGAR score. If the 1 minute score is between 4 and 8, which action should the nurse take?
- gently rub the infant’s back and administer oxygen
22) In which of these situations is a forceps-assisted birth indicated?-
for a fetal prolapsed umbilical cord
23) During the first 24 hours postpartum, a client states her vaginal discharge is bright red with small pieces of mucus. Which of these actions should the nurse take?-
hold her NPO, and immediately notify her health care provider.
24) During the immediate postpartum period, a client’s fundus is firmly contracted, midline, and at the appropriate level, but she is exhibiting an excessive amount of bleeding. Then nurse should suspect the cause of the bleeding to be:
- cervical or vaginal tears
25) A nurse would expect a postpartum client’s uterine and vaginal discharge on the 4th postpartum day to be lochia:
26) A postpartum client has a midline episiotomy and states there is a great deal of discomfort whenever she moves. To decrease the discomfort, the nurse should instruct the client to:-
tighten the buttocks and perineum before sitting and relax the area once seated
27) A postpartum client who is breastfeeding asks the nurse when her menstrual period will return. Which of these responses should the nurse make?-
“It will largely depend on your breastfeeding pattern”
28) A client who is breastfeeding experiences engorgement on the 4th postpartum day. The nurse should explain to the client that engorgement is the result of:-
vasocongestion of breast tissues as milk production begins
29) A client is exhibiting signs of postpartum depression. Which of the following symptoms would indicate the client’s condition has advanced to that of postpartum psychosis?-
obsessive concerns about the infant’s health
30) The Newborn’s and Mothers’ Health Protection Act of 1995 mandates that all health care plans require a minimal postpartum hospital stay of how many hours for vaginal and cesarean births?
-vaginal, 48; cesarean 96
31) Which of these actions is essential when a nurse is caring for a postpartum client who is getting out of bed for the first time?
- stay with the client during ambulation
32) The normal postpartum uterus has which of these characteristics?
- firm and in the midline
33) While palpating a client’s uterus postpartum, the nurse notes the fundus position to be 2cm higher than on previous assessments and off to the left side. Which of these actions should the nurse take?
- ask the client to urinate, and then reassess the fundus position
34) Which of these descriptions of lochia is expected of a mother who had a cesarean delivery?
- is smaller in amount than that of a mother who has had a vaginal birth
35) A client with blood type B negative has given birth to an infant with blood type O positive. When should the client receive Rh immune globulin?
- within 72 hours after delivery
36) If a nurse observes an increased pulse rate and decreased blood pressure in a new postpartum client, the nurse should suspect the client has developed which of these conditions?
- postpartum hemorrhage
37) A breastfeeding client who is 2 weeks postpartum tells the nurse her nipples are very sore and is able to breastfeed for only short periods. The nurse should recognize the client is at risk for developing:
38) To decrease the incidence of thromboembolic conditions in a postpartum client, the nurse would encourage the client to:
- ambulate early and frequently after delivery
39) The nurse caring for an expectant mother would monitor for which of the following that predisposes the mother for a risk of bleeding?
- decreased platelet level
- alcohol abuse
- taking NSAIDs
- herbal medications
40) When the nurse is caring for a postpartum client, assessment would be focused on which priority areas?
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