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- A nurse in the labor and delivery unit receives a phone call from a client who reports that her contrac- tions started about 2 hr. ago, did not go away when she had two glasses of water and rested, and became stronger since she started walking. Her contractions occur every 10 min and last about 30 seconds. She hasn't had a fluid leak form her vagina. However, she saw some blood when she wiped after voiding. Based on this report, which of the following clinical findings should the nurse recognize that the client is experienc- ing a. Braxton hick's contractions b. Rupture of membranes c. Fetal descent d. True contractions
- A nurse in the labor and delivery unit is caring for a client in labor and applies an external fetal moni- tor and tocotransducer. The FHR is around 140/min. contractions are occurring every 8 min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of labor is the client experiencing a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage of labor
- A client experiences a large gush of fluid from her
D - true contractions
A - first stage, latent phase
B - monitor the fetal hear
vagina while walking in the hallway of the birthing unit. rate for distress
Which of the following actions should the nurse take
tion. Which of the following actions should the nurse take? (select all that apply) a. Encourage the use of patterned breathing tech- niques b. Insert an indwelling urinary catheter c. Administer opioid analgesic medication d. Suggest application of cold e. Provide ice chips
- A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects this pain is related to a persistent occiput posterior fetal position which of the following nonpharm nurs- ing interventions should the nurse recommend to the client? a. An abdominal effleurage b. Sacral counterpressure c. Showering if not contraindicated d. Back rub and massage
- A nurse is caring for a client following the adminis-
D - suggest application of cold
B - sacral counterpressure
C - it is needed to counter-
tration of an epidural block and is preparing to admin- act hypotension ister an IV fluid bolus. The clients partner asks about the purpose of the IV fluids. Which of the following is an appropriate response for the nurse to make? a. It is needed to promote increased urine output b. It is needed to counteract respiratory depression c. It is needed to counteract hypotension d. It is needed to prevent oligohydramnios
- A nurse is caring for a client who is in the second stage of labor. The clients
labor has been progressing, (^) A - pudendal
d. Normal baseline FHR e. Fetal tachycardia
- A nurse is teaching a client about the benefits of B - it can detect abnormal
internal fetal heart monitoring. Which of the following fetal heart tones early should the nurse include in the teaching? (select all that apply) a. It is considered a noninvasive procedure b. It can detect abnormal fetal heart tones early c. It can determine the amount of amniotic fluid you have d. It allows for accurate readings with maternal move- ment e. It can measure uterine contraction intensity
- A nurse is reviewing the electronic monitor tracing
D - it allows for accu- rate readings with mater- nal movement E - it can measure uterine contraction intensity
D - relaxation between
of a client who is in active labor. The nurse should know uterine contractions that fetus receives more oxygen when which of the following appears on the tracing? a. Peak of the uterine contraction b. Moderate variability c. FHR acceleration d. Relaxation between uterine contractions
- A nurse is caring for a client who is in labor and ob- serves late decelerations on the electronic fetal moni- tor. Which of the following is the first action the nurse should take? a. Assist the client into the left lateral position b. Apply a fetal scalp electrode c. Insert an IV catheter
d. Perform a vaginal exam
A - assist the client into the left lateral position
- A nurse is caring for a client in the third stage of A - lengthening of the um- labor. Which of the following findings indicate that pla- bilical cord cental separation has occurred? (select all that apply) a. Lengthening of the umbilical cord b. Swift gush of clear amniotic fluid c. Softening of the lower uterine segment d. Appearance of dark blood from the vagina e. Fundus firm upon palpation
- A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having g vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? a. Inspect the introitus for a prolapsed cord b. Perform a test to identify the feming pattern c. Monitor station of the presenting part d. Defer vaginal examinations
D - appearance of dark blood from the vagina E - fundus firm upon pal- pation
D - defer vaginal examina- tions
- A nurse is caring for a client who is in the first stage D - a distended blad- of labor and is encouraging the client to void every 2 der reduces pelvic space hr. which of the following statements should the nurse needed for birth make? a. A full bladder increases the risk for fetal trauma b. A full bladder increases the risk for bladder infec- tions c. A distended bladder will be traumatized by frequent pelvic exams d. A distended bladder reduces pelvic space needed for birth
A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and deliv- ery unit. During and ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to be an amnioin- fusion. Which of the following conditions should the nurse plan to prepare an amnioinfusion? (select all that apply) a. Oligohydramnios b. Hydramnios c. Fetal cord compression d. Hydration e. Fetal immaturity
- A nurse is caring for a client who has been in labor for 12 hr. and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? a. Fetal engagement b. Fetal lie c. Fetal attitude d. Fetal position
- A nurse is caring for a client who had no prenatal care, is rH negative and will undergo an external ver- sion at 37 weeks of gestation. Which of the following medication should the nurse plan to administer prior to the version? a. Prostaglandin gel b. Magnesium sulfate
A - oligohydramnios C - fetal cord compression
A - fetal engagement
C - Rho (D) immune glob- ulin
- A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? a. Hands and knees b. Lithotomy c. Trendelenburg d. Supine with a rolled towel under one hip
- A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible com- plications should the nurse observe? a. Precipitous labor b. Premature rupture of membranes c. Post maturity syndrome d. Prolapsed umbilical cord
- A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? a. Intrauterine growth restriction b. Hyperglycemia c. Meconium aspiration d. Polyhydramnios
A - hands and knees
D - prolapsed umbilical cord
C - meconium aspiration
- A nurse is caring for a client in active labor. When last D - call for assistance examined 2 hr. ago, the clients cervix was 3 cm dilated, 100% effaced, membranes intact and the fetus was at
-2 station. The client suddenly states "my water broke" the monitor reveals a FHR of 80 to 85 per min, and the nurse performs a vaginal examination, noticing clear fluid and pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. Place the client in Trendelenburg position b. Apply pressure to the presenting par with her fin- gers c. Administer oxygen at 10 L/min via a face mask d. Call for assistance
