NRSG 3460 Nrsing in the Childbearing Fam Georgia College and State University The cervix is dilated completely A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? Administer oxygen via face mask A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: Fetal heart rate of 180 beats per minute A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? Supine position with a wedge under the right hip A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: Palpating the maternal radial pulse while listening to the fetal heart rate A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? Continuous electronic fetal monitoring A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? Notify the physician or nurse mid-wife A 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 BPM. Which of the following nursing actions is most appropriate?
A 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 of the following actions is most appropriate? Assessing the baseline fetal heart rate A 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 monitor, the initial nursing assessment is which of the following? 1 cm above the ischial spine A 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 -1 station. The nurse determines that the fetal presenting part is: A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client’s hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? A 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: Increased efficiency of contractions A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?
A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: 1. Stop of pitocin infusion; 2. Check the client's blood pressure and heart rate; 3. Reposition the client (side-lying); 4. Administer oxygen by face mask at 8 to 10 L/min; 5. Perform a vaginal examination A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. Oxytocin (Pitocin) infusion A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician’s orders and would expect to note which of the following prescribed treatments for this condition? Provide pain relief measures A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: Monitoring fetal heart rate A nurse is 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 of care and selects which of the following nursing interventions as the highest priority?
A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? Changes in the shape of the uterus A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? Place the client in Trendelenburg's position A nurse in the 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. Which of the following would be the initial nursing action? Swelling of the calf in one leg A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician’s orders and would question which order? An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? Auscultating the fetal heart A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus’ head is: Below the umbilicus on the right side After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: To the beginning of the next contraction The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:
The nurse observes the client’s amniotic fluid and decides that it appears normal, because it is:
At 38 weeks’ gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: Change the client's position When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: The breathing technique that the mother should be instructed to use as the fetus’ head is crowning is: During the period of induction of labor, a client should be observed carefully for signs of:
A client arrives at the hospital in the second stage of labor. The fetus’ head is crowning, the client is bearing down, and the birth appears imminent. The nurse should:
A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she: Which of the following observations indicates fetal distress? Which of the following fetal positions is most favorable for birth? A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor? A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly? Perform a pelvic examination A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond?
Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors?
Fetal presentation refers to which of the following descriptions? A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates titanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?
Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? Variability averages between 6-10 bpm Which of the following findings meets the criteria of a reassuring FHR pattern? Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to: The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: |
The nurse observes the clients amniotic fluid and decides that it appears normal, because it is
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