NClex-PN Maternity- Intrapartum

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  1. The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?
    Lateral Sims'
  2. The nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which?
    Signs of shock
  3. A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms would indicate that the client's bleeding is caused by placenta previa?Select all that apply.
    • Bright red vaginal bleeding
    • Lack of uterine contractions
  4. A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid which measure at this time to assist in relieving the back discomfort?
    Assist the client to ambulate in the room.
  5. The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?
    A manual pelvic examination
  6. A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse include in the plan of care?
    Maintain complete bed rest, monitor IV fluid intake, and monitor the fetal heart rate.
  7. The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?
    Provide pain relief measures.
  8. The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted?
    Presence of accelerations
  9. After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?
    Support the mother in her reaction to the newborn.
  10. A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?
    "What an efficient way to record my baby's heart rate."
  11. The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, which action should the nurse take initially?
    Determine the maternal and fetal vital signs.
  12. The nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
    Changes in the shape of the uterus
  13. The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?
    Effleurage is light stroking of the abdomen to facilitate relaxation during labor.
  14. After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of which condition?
    Placental separation
  15. The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?
    Newborn
  16. The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.
    • The fetus is in the breech position.
    • Lesions are present on the perineum.
    • The fetus is not settled into the pelvis.
  17. The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?
    "My cervix is completely dilated."
  18. Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.
    • Constant fever of 101° F
    • Persistent pelvic heaviness
    • Foul-smelling vaginal discharge
  19. The nurse should prepare to give a prescribed oxytocic medication after delivery of which?
    Placenta
  20. A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need isprimary to the client at this time?
    Rest between contractions
  21. A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding would be noted if complete rupture occurs?
    Decreasing blood pressure
  22. The advantages of using spinal anesthesia for delivery of a fetus include which? Select all that apply.
    • Ease of administration
    • Absence of fetal hypoxia
    • Immediate onset of anesthesia
  23. Ease of administration 2.Absence of fetal hypoxia 3.Immediate onset of anesthesia
    Pain level is "4" while a progressive labor pattern continues.
  24. A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?
    Encourage the client to discuss her concerns and desires regarding anesthesia options.
  25. The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action?
    Continue to monitor the client.
  26. A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicates to the nurse the presence of concealed bleeding?
    Increase in fundal height
  27. The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client?
    "Leopold's maneuvers are used to determine fetal position."
  28. A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem?
    Anxiety and fear
  29. A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position?
    Supine with a wedge under the right hip
  30. The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (–) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?
    Complete bed rest
  31. The nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? Select all that apply.
    • Signs of fetal distress
    • High level of maternal anxiety
    • Failure of the fetus to descend
  32. The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which at this time?
    Continue monitoring the client because the data reflect acceptable progress.
  33. The nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC?
    Swelling of the calf of one leg
  34. The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problems should the nurse expect to note on the plan of care?
    Anxiety related to a slow progress of labor
  35. The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding?
    Uterine tenderness on palpation
  36. The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?
    A change in the uterine contour
  37. The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?
    Monitoring fetal status
  38. If a precipitate delivery is imminent, which would be the appropriate nursing action?
    Put on sterile gloves, and gently guide the baby's head and shoulders out.
  39. The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?
    Baseline fetal heart rate
  40. A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?
    The client feels hopeless about the situation.
  41. A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior the nurse should suspect the client is how far dilated?
    8 to 10 cm
  42. A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure?
    A cesarean birth
  43. A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?
    Check the fetal heart rate.
  44. When examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply.
    • One vein
    • Two arteries
  45. The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply
    • Bright red vaginal bleeding
    • Soft, relaxed, nontender uterus
  46. Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?
    Change in uterine shape
  47. The nurse is monitoring a client in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, how should the nurse respond?
    Administer oxygen via face mask to the mother.
  48. Which would be the appropriate method to use to deliver the placenta after a precipitate delivery?
    Gently guide the placenta out after a spontaneous separation.
  49. The nurse is caring for a client in labor. The nurse reviews the health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. The nurse understands that the action of this medication is to have which effect?
    Decrease pain.
  50. The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
    Minus (–) 1 station
  51. A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock?
    Restlessness and agitation
  52. At 5:00 am a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 am with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action?
    Prepare the client for a cesarean delivery.
  53. A client was admitted to the maternity unit 12 hours ago and has been experiencing strong contractions every 3 minutes, and the fetus is currently at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. Which nursing action is appropriate?
    Prepare the client for a cesarean delivery.
  54. The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
    Have the client empty her bladder.
  55. A client in preterm labor is placed on bed rest. The nurse assists the client to which advantageous position?
    Left lateral
  56. A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor?Select all that apply.
    • Encourage frequent urination.
    • Continue maternal and fetal assessments.
    • Review breathing and relaxation techniques.
  57. The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?
    Intravenous (IV) supplies
  58. A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse?
    Respirations of 10 breaths per minute
  59. Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers?
    The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.
  60. For the previous 4 hours, a client in labor has been experiencing contractions every 2 minutes lasting 60 to 70 seconds and strong to palpation. She is dilated 2 cm and complaining of severe pain. The nurse understands that the client is experiencing which type of dystocia?
    Hypertonic
  61. The nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is in which position?
    1 cm above the ischial spines
  62. The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, the nurse understands that which nursing action will promote the birth of the placenta?
    Putting the baby to the mother's breast and letting the baby suck
  63. The nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding which is the nurse's priority action?
    Stop the oxytocin infusion.
  64. A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which action to assist in preventing a crisis from occurring during labor?
    Administer oxygen as prescribed.
  65. The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
    Minus (–) 1 station
  66. After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of which condition?
    Placental separation
  67. The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?
    Keep the client in a side-lying position.
  68. A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?
    Determine the parents' desires for contact with the newborn.
  69. The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which as least likely necessary for the care of this client?
    Measuring the fundal height
  70. The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action?
    Monitor the fetal heart rate.
  71. The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?
    White blood cell count of 35,000 cells/mm3
  72. The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?
    Provide pain relief measures.
  73. The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?
    Fear of losing control
  74. The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, which action should the nurse take initially?
    Determine the maternal and fetal vital signs.
  75. The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is themost important information for the nurse to document on the strip?
    Maternal vital signs
  76. The nurse is assigned to care for a client experiencing dystocia. Which would be the highest priority in planning care?
    Monitoring for changes in the physical and emotional condition of the mother and fetus
  77. The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document that the FHR is normal if which result is noted?
    150 beats per minute

Card Set Information

Author:
Huntpeytmom
ID:
320675
Filename:
NClex-PN Maternity- Intrapartum
Updated:
2016-06-02 04:14:39
Tags:
intrapartum
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Description:
Saunders Comprehensive Review for the NCLEX-PN Examination Maternity- Intrapartum
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