Maternity - Intrapartum

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nursedaisy98
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256737
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Maternity - Intrapartum
Updated:
2014-04-19 23:46:46
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NCLEX RN
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Maternity
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Intrapartum
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  1. A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus?
    1. Connects the pulmonary artery to the aorta
    2. Is an opening between the right and left atria
    3. Connects the umbilical vein to the inferior vena cava
    4. Connects the umbilical artery to the inferior vena cava
    3. Connects the umbilical vein to the inferior vena cava
  2. The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation?
    1. A primigravida with mild preeclampsia
    2. A primigravida who delivered a 10-lb infant 3 hours ago
    3. A gravida II who has just been diagnosed with dead fetus syndrome
    4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood
    3. A gravida II who has just been diagnosed with dead fetus syndrome
  3. The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
    1. The contractions are regular.
    2. The membranes have ruptured.
    3. The cervix is dilated completely.
    4. The client begins to expel clear vaginal fluid.
    3. The cervix is dilated completely.
  4. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?
    1. Administer oxygen via face mask.
    2. Place the mother in a supine position.
    3. Increase the rate of the oxytocin (Pitocin) intravenous infusion.
    4. Document the findings and continue to monitor the fetal patterns.
    1. Administer oxygen via face mask.
  5. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?
    1. Hemoglobin of 11 g/dL
    2. Fetal heart rate of 180 beats/minute
    3. Maternal pulse rate of 85 beats/minute
    4. White blood cell count of 12,000 cells/mm3
    2. Fetal heart rate of 180 beats/minute
  6. The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the –1 station. This documented finding indicates that the fetal presenting part is located at which area?
    1. 1 inch below the coccyx
    2. 1 inch below the iliac crest
    3. 1 cm above the ischial spine
    4. 1 fingerbreadth below the symphysis pubis
    3. 1 cm above the ischial spine
  7. A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy?
    1. Less pressure on her cervix
    2. Decreased number of contractions
    3. Increased efficiency of contractions
    4. The need for increased maternal blood pressure monitoring
    3. Increased efficiency of contractions
  8. The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
    1. Variability
    2. Accelerations
    3. Early decelerations
    4. Variable decelerations
    4. Variable decelerations
  9. A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?
    1. Supine position with a wedge under the right hip
    2. Trendelenburg's position with the legs in stirrups
    3. Prone position with the legs separated and elevated
    4. Semi-Fowler's position with a pillow under the knees
    1. Supine position with a wedge under the right hip
  10. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?
    1. Notify the health care provider (HCP).
    2. Continue monitoring the fetal heart rate.
    3. Encourage the client to continue pushing with each contraction.
    4. Instruct the client's coach to continue to encourage breathing techniques.
    1. Notify the health care provider (HCP).
  11. The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
    1. Notify the health care provider of the findings.
    2. Reposition the mother and check the monitor for changes in the fetal tracing.
    3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen.
    4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
    4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
  12. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?
    1. Identify the types of accelerations.
    2. Assess the baseline fetal heart rate.
    3. Determine the intensity of the contractions.
    4. Determine the frequency of the contractions.
    2. Assess the baseline fetal heart rate.
  13. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?
    1. "I won't be in labor until my baby drops."
    2. "My contractions will be felt in my abdominal area."
    3. "My contractions will not be as painful if I walk around."
    4. "My contractions will increase in duration and intensity."
    4. "My contractions will increase in duration and intensity."
  14. Which assessment finding following an amniotomy should be conducted first?
    1. Cervical dilation
    2. Bladder distention
    3. Fetal heart rate pattern
    4. Maternal blood pressure
    3. Fetal heart rate pattern
  15. The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?
    1. Ambulation
    2. Rest between contractions
    3. Change positions frequently
    4. Consume oral food and fluids
    2. Rest between contractions
  16. The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?
    1. Notify the health care provider.
    2. Discontinue the infusion of oxytocin (Pitocin).
    3. Place oxygen on at 8 to 10 L/minute via face mask.
    4. Contact the client's primary support person(s) if not currently present.
    2. Discontinue the infusion of oxytocin (Pitocin).
  17. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?
    1. Soft abdomen
    2. Uterine tenderness
    3. Absence of abdominal pain
    4. Painless, bright red vaginal bleeding
    2. Uterine tenderness
  18. The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?
    1. Prepare the client for an ultrasound.
    2. Obtain equipment for a manual pelvic examination.
    3. Prepare to draw a hemoglobin and hematocrit blood sample.
    4. Obtain equipment for external electronic fetal heart rate monitoring.
    2. Obtain equipment for a manual pelvic examination.
  19. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?
    1. Delivery of the fetus
    2. Strict monitoring of intake and output
    3. Complete bed rest for the remainder of the pregnancy
    4. The need for weekly monitoring of coagulation studies until the time of delivery
    1. Delivery of the fetus
  20. The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?
    1. Hypotonic
    2. Precipitous
    3. Hypertonic
    4. Preterm labor
    1. Hypotonic
  21. The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise?
    1. Maternal fatigue
    2. Coordinated uterine contractions
    3. Progressive changes in the cervix
    4. Persistent nonreassuring fetal heart rate
    4. Persistent nonreassuring fetal heart rate
  22. The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?
    1. Provide pain relief measures.
    2. Prepare the client for an amniotomy.
    3. Promote ambulation every 30 minutes.
    4. Monitor the oxytocin (Pitocin) infusion closely.
    1. Provide pain relief measures.
  23. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?
    1. Monitor fetal heart rate continuously.
    2. Monitor maternal vital signs frequently.
    3. Perform a vaginal examination every shift.
    4. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.
    3. Perform a vaginal examination every shift.
  24. The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?
    1. Providing comfort measures
    2. Monitoring the fetal heart rate
    3. Changing the client's position frequently
    4. Keeping the significant other informed of the progress of the labor
    2. Monitoring the fetal heart rate
  25. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?
    1. Slow the intravenous flow rate.
    2. Place the client in a high Fowler's position.
    3. Continue the oxytocin (Pitocin) drip if infusing.
    4. Administer oxygen, 8 to 10 L/minute, via face mask.
    4. Administer oxygen, 8 to 10 L/minute, via face mask.
  26. The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply.
    1. Uterine rigidity
    2. Uterine tenderness
    3. Severe abdominal pain
    4. Bright red vaginal bleeding
    5. Soft, relaxed, nontender uterus
    6. Fundal height may be greater than expected for gestational age.
    • 4. Bright red vaginal bleeding
    • 5. Soft, relaxed, nontender uterus
    • 6. Fundal height may be greater than expected for gestational age.
  27. The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?
    1. Gently push the cord into the vagina.
    2. Place the client in Trendelenburg's position.
    3. Find the closest telephone and page the health care provider stat.
    4. Call the delivery room to notify the staff that the client will be transported immediately.
    2. Place the client in Trendelenburg's position.
  28. A nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time?
    1. The client's fear
    2. The client's fatigue
    3. The client's inability to control the situation
    4. The client's inability to cope with the situation
    1. The client's fear
  29. The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation. Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply.
    1. Hematuria
    2. Prolonged clotting times
    3. Increased platelet count
    4. Swelling of the calf of one leg
    5. Petechiae, oozing from injection sites, and hematuria
    • 1. Hematuria
    • 2. Prolonged clotting times
    • 5. Petechiae, oozing from injection sites, and hematuria
  30. The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred?
    1. Forceps delivery
    2. Schultz presentation
    3. Hypotonic contractions
    4. Weak bearing-down efforts
    1. Forceps delivery
  31. The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client?
    1. Bear down.
    2. Hold her breath.
    3. Breathe rapidly.
    4. Push with each contraction.
    3. Breathe rapidly.
  32. The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation?
    1. "It is the application of pressure to the sacrum to relieve a backache."
    2. "It is a form of biofeedback to enhance bearing-down efforts during delivery."
    3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus."
    4. "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest."
    3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus."
  33. A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse plan to assess and document the fetal heart rate?
    1. Hourly
    2. Every 15 minutes
    3. Every 30 minutes
    4. Before each contraction
    2. Every 15 minutes
  34. The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately?
    1. Noting whether the heart rate is greater than 140 beats/min
    2. Placing the diaphragm of the Doppler on the mother's abdomen
    3. Palpating the maternal radial pulse while listening to the fetal heart rate
    4. Performing Leopold's maneuver first to determine the location of the fetal heart
    3. Palpating the maternal radial pulse while listening to the fetal heart rate
  35. The nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued?
    1. Increased urinary output
    2. A fetal heart rate of 90 beats/min
    3. Three contractions occurring within a 10-minute period
    4. Adequate resting tone of the uterus palpated between contractions
    2. A fetal heart rate of 90 beats/min
  36. The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which intervention is implemented before initiating the infusion?
    1. An IV infusion of antibiotics
    2. Placing the client on complete bed rest
    3. Continuous electronic fetal monitoring
    4. Placing a code cart at the client's bedside
    3. Continuous electronic fetal monitoring
  37. The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition?
    1. Hematoma
    2. Uterine atony
    3. Placenta previa
    4. Placental separation
    4. Placental separation
  38. During the intrapartum period, a nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome?
    1. Stimulate the labor process.
    2. Prevent dehydration and hypoxemia.
    3. Avoid the necessity of a cesarean delivery.
    4. Eliminate the need for analgesic administration.
    2. Prevent dehydration and hypoxemia.
  39. A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client?
    1. Measure fundal height.
    2. Attach electronic fetal monitoring.
    3. Prepare the client for a possible cesarean section.
    4. Visually examine the perineum and vaginal opening.
    1. Measure fundal height.
  40. The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action?
    1. Administer oxygen by face mask.
    2. Clear and maintain an open airway.
    3. Administer magnesium sulfate intravenously.
    4. Assess the blood pressure and fetal heart rate.
    2. Clear and maintain an open airway.
  41. A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted?
    1. Back pain
    2. Abdominal pain
    3. Painful vaginal bleeding
    4. Painless vaginal bleeding
    4. Painless vaginal bleeding
  42. A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment finding would indicate the presence of concealed bleeding?
    1. Back pain
    2. Heavy vaginal bleeding
    3. Increase in fundal height
    4. Early deceleration on the fetal heart monitor
    3. Increase in fundal height
  43. The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action?
    1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.
    2. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min.
    3. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min.
    4. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.
    1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.
  44. An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal?
    1. Light green, with no odor
    2. Clear and dark amber-colored
    3. Thick and white, with no odor
    4. Pale straw-colored, with flecks of vernix
    4. Pale straw-colored, with flecks of vernix
  45. A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/min and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?
    1. Contact the obstetrician.
    2. Continue to monitor the client.
    3. Report the FHR to the anesthesiologist.
    4. Prepare for imminent delivery of the fetus.
    2. Continue to monitor the client.
  46. The nurse is developing a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply.
    1. Keep the room semi-dark.
    2. Initiate seizure precautions.
    3. Pad the side rails of the bed.
    4. Avoid environmental stimulation.
    5. Allow out-of-bed activity as tolerated.
    • 1. Keep the room semi-dark.
    • 2. Initiate seizure precautions.
    • 3. Pad the side rails of the bed.
    • 4. Avoid environmental stimulation.
  47. The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia?
    1. Assessing the mother's reflexes
    2. Taking the mother's temperature
    3. Taking the mother's apical pulse
    4. Monitoring the mother's blood pressure
    4. Monitoring the mother's blood pressure
  48. A nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure?
    1. Assess the fetal heart rate.
    2. Check the client's temperature.
    3. Change the pads under the client.
    4. Check the client's respiratory rate.
    1. Assess the fetal heart rate.
  49. The goal for a woman with partial premature separation of the placenta is, "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, would indicate that this goal has been achieved?
    1. No accelerations of FHR
    2. Short-term variability present
    3. Variable decelerations present
    4. Fetal heart rate (FHR) of 170 to 180 beats/min
    2. Short-term variability present
  50. The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex?

    1. A
    2. B
    3. C
    4. D
    1. A
  51. The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate decelerations?
    1. Prepare the client for a cesarean delivery.
    2. Monitor the fetal heart rate every 30 minutes.
    3. Encourage an upright or side-lying maternal position.
    4. Increase the rate of the oxytocin (Pitocin) infusion every 10 minutes.
    3. Encourage an upright or side-lying maternal position.
  52. The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client?
    1. Assess for signs and symptoms of labor.
    2. Assess the client's temperature every 2 hours.
    3. Schedule a daily ultrasound to assess fetal movement.
    4. Schedule a non-stress test every 4 hours to assess fetal well-being.
    1. Assess for signs and symptoms of labor.
  53. The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency?
    1. Fentanyl
    2. Morphine sulfate
    3. Butorphanol tartrate
    4. Meperidine hydrochloride (Demerol)
    3. Butorphanol tartrate
  54. The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention?
    1. Chest pain
    2. A rigid abdomen
    3. A soft and boggy uterus
    4. Complaints of severe abdominal pain
    4. Complaints of severe abdominal pain
  55. The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior?
    1. Exhaustion
    2. Valsalva maneuver
    3. Involuntary grunting
    4. Fear of losing control
    4. Fear of losing control
  56. A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for throughout the client's labor?
    1. Anxiety
    2. Hemorrhage
    3. Low self-esteem
    4. Postpartum infection
    4. Postpartum infection
  57. Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement?
    1. Slow the intravenous (IV) rate.
    2. Continue the oxytocin (Pitocin) drip.
    3. Place the client in a high Fowler's position.
    4. Administer oxygen at 8 to 10 L/min via face mask.
    4. Administer oxygen at 8 to 10 L/min via face mask.
  58. A pregnant 39-week-gestation gravida 1 para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B Streptococcus(GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action?
    1. Provide the client with instructions on how to push.
    2. Prepare the labor room and the client for an imminent delivery.
    3. Call the HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP).
    4. Call the health care provider (HCP) to the labor and delivery unit to perform a delivery.
    3. Call the HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP).
  59. A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action?
    1. Perform an abdominal prep on the client.
    2. Prepare the delivery room for a vaginal delivery.
    3. Explain to the client why a cesarean delivery is necessary.
    4. Call the health care provider to obtain a prescription for an antiviral medication.
    3. Explain to the client why a cesarean delivery is necessary.
  60. The nurse caring for a client in labor notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which best describes minimal variability?
    1. FHR fluctuations are lasting more than 15 seconds.
    2. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate.
    3. FHR fluctuations are lasting more than 15 seconds.
    4. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate.
    1. FHR fluctuations are lasting more than 15 seconds.
  61. After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action?
    1. Reposition the laboring woman to knee-chest.
    2. Assess the vagina and cervix with a gloved hand.
    3. Notify the health care provider of the need for an amnioinfusion.
    4. Document the description of the fetal bradycardia in the nursing notes.
    2. Assess the vagina and cervix with a gloved hand.
  62. On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies is which category of decelerations?
    1. Episodic, late decelerations that indicate uteroplacental insufficiency
    2. Periodic, early decelerations and indicative of fetal head compression
    3. Periodic, variable decelerations and an indication of cord compression
    4. Episodic, early decelerations that may be a result of maternal hypotension
    2. Periodic, early decelerations and indicative of fetal head compression
  63. Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply.
    1. Prepare for delivery.
    2. Administer a tocolytic.
    3. Administer an opioid antagonist.
    4. Turn the woman to a lateral position.
    5. Increase the rate of the intravenous infusion.
    6. Administer oxygen by face mask at 10 L/minute.
    • 4. Turn the woman to a lateral position.
    • 5. Increase the rate of the intravenous infusion.
    • 6. Administer oxygen by face mask at 10 L/minute.
  64. The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response?
    1. "The medication will only affect you and your pain level when given during a contraction."
    2. "The medication will provide the most optimal relief when it is given while your pain level is highest."
    3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication."
    4. "You will experience a lower incidence of adverse effects from the medication when administered during a contraction."
    3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication."
  65. On March 10, 2015, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7, 2014. The nurse plans care based on which interpretation?
    1. The client is possibly in preterm labor.
    2. The fetus may not be viable at delivery.
    3. The client may require labor augmentation.
    4. The fetus is at high risk for shoulder dystocia.
    1. The client is possibly in preterm labor.
  66. The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and would expect to note which prescribed treatment for this condition?
    1. Increased hydration
    2. Oxytocin (Pitocin) infusion
    3. Administration of a tocolytic medication
    4. Administration of a medication that will provide sedation
    2. Oxytocin (Pitocin) infusion
  67. Which newborn is most at risk for a brachial plexus injury?
    1. A term infant with a history of a forceps-assisted delivery
    2. A term infant delivered via primary cesarean section for malpresentation
    3. A large for gestational age infant with a history of shoulder dystocia at delivery
    4. A 36-week preterm infant delivered vaginally after preterm rupture of membranes
    3. A large for gestational age infant with a history of shoulder dystocia at delivery
  68. A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider (HCP) has prescribed an epidural block. Which nursing intervention would be implemented after the epidural block has been placed?
    1. Palpate the bladder at frequent intervals.
    2. Encourage the woman to walk to progress the labor.
    3. Assess the blood pressure frequently for hypertension.
    4. Encourage the woman to assume a supine position after the epidural has been placed.
    1. Palpate the bladder at frequent intervals.
  69. A nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action?
    1. Administer oxygen to the woman.
    2. Transport the woman to the delivery room.
    3. Place an external fetal monitor on the woman.
    4. Exert upward pressure against the presenting part using a gloved hand.
    4. Exert upward pressure against the presenting part using a gloved hand.
  70. A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action?
    1. Contact the health care provider.
    2. Place the mother in a Trendelenburg position.
    3. Administer oxygen to the client by face mask.
    4. Document the findings and continue to monitor fetal patterns.
    4. Document the findings and continue to monitor fetal patterns.
  71. The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first?
    1. Stop the oxytocin infusion.
    2. Check the client's blood pressure.
    3. Check the client for bladder distention.
    4. Place the client in a side-lying position.
    1. Stop the oxytocin infusion.
  72. A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which is documented in the client's record?
    1. The contractions are regular.
    2. The membranes have ruptured.
    3. The cervix is completely dilated.
    4. The client begins to expel clear vaginal fluid.
    3. The cervix is completely dilated.
  73. A nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding the nurse should prepare for which appropriate nursing action?
    1. Administering oxygen via face mask
    2. Placing the mother in a supine position
    3. Increasing the rate of the intravenous (IV) oxytocin (Pitocin) infusion
    4. Documenting the findings and continuing to monitor the fetal patterns
    1. Administering oxygen via face mask
  74. A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of the infusion needs to be decreased?
    1. Increased urinary output
    2. A fetal heart rate of 180 beats/min
    3. Three contractions occurring in a 10-minute period
    4. Adequate resting tone of the uterus palpated between contractions
    2. A fetal heart rate of 180 beats/min
  75. A nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action?
    1. Determine the fetal heart rate.
    2. Provide peripads for the client.
    3. Take the client's blood pressure.
    4. Note the amount, color, and odor of the amniotic fluid.
    1. Determine the fetal heart rate.
  76. A nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse should document these observations as signs of which condition?
    1. Hematoma
    2. Uterine atony
    3. Placenta previa
    4. Placental separation
    4. Placental separation
  77. A nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse should ensure that which is implemented before the beginning of the infusion?
    1. An IV infusion of antibiotics
    2. Placing the client on complete bed rest
    3. Continuous electronic fetal monitoring
    4. Placing a code cart at the client's bedside
    3. Continuous electronic fetal monitoring
  78. A nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should assess that the amniotic fluid is normal if it has which characteristics?
    1. Clear and dark amber color
    2. Light green color with no odor
    3. Thick white color with no odor
    4. Straw-colored, with flecks of vernix
    4. Straw-colored, with flecks of vernix
  79. A nurse is developing a plan of care for a client experiencing dystocia, and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?
    1. Monitoring fetal status
    2. Providing comfort measures
    3. Changing the client's position frequently
    4. Keeping the significant other informed of the progress of the labor
    1. Monitoring fetal status
  80. A nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?
    1. Maternal fatigue
    2. The passage of meconium
    3. Coordinated uterine contractions
    4. Progressive changes in the cervix
    2. The passage of meconium
  81. A nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention?
    1. Provide pain relief measures.
    2. Prepare the client for an amniotomy.
    3. Promote ambulation every 30 minutes.
    4. Monitor the oxytocin (Pitocin) infusion closely.
    1. Provide pain relief measures.
  82. A nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?
    1. Gently push the cord into the vagina.
    2. Place the client in Trendelenburg's position.
    3. Find the closest telephone and page the health care provider stat.
    4. Call the delivery room to notify the staff that the client will be transported immediately.
    2. Place the client in Trendelenburg's position.
  83. A nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action?
    1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min.
    2. Turn the client on her back and administer oxygen by face mask at 8 to 10 L/min.
    3. Turn the client on her side and administer oxygen by nasal cannula at 2 to 4 L/min.
    4. Turn the client on her back and administer oxygen by nasal cannula at 2 to 4 L/min.
    1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min.
  84. An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?
    1. Delivery of the fetus
    2. Strict monitoring of intake and output
    3. Complete bed rest for the remainder of the pregnancy
    4. The need for weekly monitoring of coagulation studies until the time of delivery
    1. Delivery of the fetus
  85. A nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?
    1. Hypotonic
    2. Precipitate
    3. Hypertonic
    4. Preterm labor
    1. Hypotonic
  86. A nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes and have a duration of 35 seconds. Using this information, what is the most appropriate action for the nurse to take?
    1. Prepare for imminent delivery.
    2. Continue to monitor the client.
    3. Report the findings to the obstetrician.
    4. Report the FHR to the anesthesiologist on call.
    2. Continue to monitor the client.
  87. A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the most appropriate nursing action?
    1. Sit the client in a high Fowler's position.
    2. Call the pharmacy for a tocolytic medication.
    3. Get intravenous (IV) therapy equipment and solution from the storage area.
    4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.
    4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.
  88. The purpose of a vaginal examination is to specifically assess the status of which findings? Select all that apply.
    1. Station
    2. Dilation
    3. Effacement
    4. Bloody show
    5. Contraction effort
    • 1. Station
    • 2. Dilation
    • 3. Effacement
  89. A nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply.
    1. Uterine tenderness
    2. Acute abdominal pain
    3. A hard, "board-like" abdomen
    4. Painless, bright red vaginal bleeding
    5. Increased uterine resting tone on fetal monitoring
    • 1. Uterine tenderness
    • 2. Acute abdominal pain
    • 3. A hard, "board-like" abdomen
    • 5. Increased uterine resting tone on fetal monitoring

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