1. (Select all that apply) A nurse is assigned to assist with the admission of a client who is in labor. Which of the following actions are appropriate? -
... [Show More] ✔✔(1) Asking about the estimated date of delivery (EDD), (3) Taking maternal and fetal vital signs, (6) Asking about the amount of time between contractions
2. Which of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor? - ✔✔Tetanic contractions
3. Which intervention should be included in the safety plan for the maternal-infant unit? - ✔✔Making sure that the spouse or significant other wears an identification band
4. When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor? - ✔✔Transitional phase
5. After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count, urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive, although the client doesn't have signs and symptoms of this disease. What is the significance of this finding? - ✔✔Maternal gonorrhea may cause an eye infection in the neonate.
6. A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings? - ✔✔A vaginal laceration
7. A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best? - ✔✔Assisting the client to ambulate in the room
8. When caring for a client who's a primigravida, the nurse would expect the second stage of labor to last how long? - ✔✔Approximately 2 hours
9. (SELECT ALL THAT APPLY) A client receives an epidural block for pain relief during labor. Which interventions by the nurse are important when caring for a client with an epidural block? - ✔✔(1) Make sure oxygen is available., (3) Monitor vital signs frequently., (5) Monitor fetal heart rate and contractions closely.
10. A client is in the second stage of labor. During this stage, how frequently should the nurse assess her uterine contractions? - ✔✔Every 15 minutes
11. Which of the following physiologic changes during labor makes it necessary for the nurse to check blood pressure frequently? - ✔✔Alterations in cardiovascular function affect the fetus.
12. A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which data collection finding may indicate the need for cesarean delivery? - ✔✔Umbilical cord prolapse
13. Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? - ✔✔An increased sense of rectal pressure
14. For a client who's moving into the active phase of labor, the nurse should include which of the following as the priority of care? - ✔✔Offer support by reviewing the short-pant form of breathing.
15. Late in the first stage of labor, a client receives a spinal block to relieve discomfort. A short time later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What do the client's symptoms suggest? - ✔✔Anesthesia overdose
16. The third stage of labor ends: - ✔✔after the birth of the placenta.
17. A client who's being admitted to labor and delivery has the following data collection findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? - ✔✔Preparing for immediate delivery
18. A client who tested positive for the human immunodeficiency virus (HIV) is in active labor. During delivery, blood splashes and contaminates the care area. Which action should the nurse take? - ✔✔Contact housekeeping and ask them to clean the area because it has been contaminated by blood-borne pathogens.
19. (SELECT ALL THAT APPLY) The nurse is assisting in the delivery room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate delivery. Which interventions should the nurse perform when caring for the client after this procedure? - ✔✔(1) Check the episiotomy repair site., (2) Apply ice to the perineum, (4) Administer pain medication, as prescribed., (5) Explain perineal care to the client when she is able to focus on the instructions.
20. A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate? - ✔✔Applying gentle pressure to the baby's head as it's delivered
21. The nurse is caring for a client who's in the first stage of labor. What is the shortest but most difficult part of this stage? - ✔✔Transitional phase
22. When coaching a client to push, the nurse should encourage her to use which technique? - ✔✔Pushing when she feels like pushing
23. A client in labor receives epidural anesthesia. The nurse should assess carefully for which adverse reaction to the anesthetic agent? - ✔✔Hypotensive crisis
24. A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be effective for the couple at this time? - ✔✔Instruct the husband on touch, massage, and breathing patterns.
25. A client in active labor is sweating profusely and has minimal urine output. How should the nurse intervene? - ✔✔Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output.
26. After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What does this finding suggest? - ✔✔Abruptio placentae
27. A client is admitted to the labor and delivery area. How can the nurse most effectively determine the duration of the client's contractions? - ✔✔By timing the period from the onset of uterine tightening to uterine relaxation
28. A client has received dinoprostone (Prostin E2) to help ripen her cervix. The nurse should monitor the client for which adverse effect? - ✔✔Vomiting
29. (SELECT ALL THAT APPLY) A client in labor is given meperidine (Demerol), 25 mg I.V., for labor pain. The nurse should monitor the client for which adverse effects of the drug? - ✔✔(2) Nausea & Vomiting, (3) Respiratory Depression, (5) Tachycardia
30. When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be: - ✔✔about half as long as her first labor.
31. A client who comes to the emergency department in the early stages of labor is admitted to the labor and delivery unit. The nurse observes that the client hasn't recently bathed or changed her clothes. What should the nurse do to help this client? - ✔✔Help the client to undress and suggest a quick bath to freshen up.
32. A client who's in active labor is yelling, "Get out of here!" As the nurse enters the client's room, she notices the client's estranged husband in the room. How should the nurse intervene? - ✔✔Ask the husband to leave or phone security.
33. Relationship of the fetus's presenting part to the mother's pelvis - ✔✔Relationship of the fetus's presenting part to the mother's pelvis
34. During a childbirth education class, a nurse-educator discusses pain control techniques used during labor and delivery. Which technique most effectively helps a client cope with the pain of uterine contractions? - ✔✔Effleurage and other cutaneous stimulation
35. A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the: - ✔✔area between the dura mater and the ligamentum flavum.
36. Which action should the nurse perform if the client's blood pressure falls during the first or second stage of labor? - ✔✔Administer oxygen through a face mask at 6 to 10 L/minute.
37. A client is in the third stage of labor. Which finding indicates impending placental separation? - ✔✔Umbilical cord lengthening
38. During the fourth stage of labor, the nurse notes that the client's fundus is boggy and located above the umbilicus. How should the nurse intervene? - ✔✔Massage the client's fundus.
39. The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary? - ✔✔Fetal heart rate of 80 beats/minute
40. During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? - ✔✔Contractions will be stronger and more uncomfortable and will peak more abruptly.
41. During the fourth stage of labor, the client should be assessed carefully for: - ✔✔uterine atony.
42. During labor, a primigravid client receives epidural anesthesia, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? - ✔✔Maternal hypotension
43. The nurse assesses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include: - ✔✔an increased pulse rate, increased respiratory rate, and decreased blood pressure.
44. A client is experiencing true labor when her contraction pattern shows: - ✔✔regular contractions that increase in frequency and duration.
45. A client who's in labor and who attended natural childbirth classes is asking for something for pain. What should the nurse do? - ✔✔Contact the physician and support the client until something can be ordered for pain.
46. When assessing the fetal heart rate tracing, the nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if which of the following occurs? - ✔✔The fetal heart rate remains at greater than 160 beats/minute for 10 minutes.
47. Which of the following should be the nurse's initial action immediately following the birth of the neonate? - ✔✔Which of the following should be the nurse's initial action immediately following the birth of the neonate?
48. (SELECT ALL THAT APPLY) The nurse is assisting in caring for a client who has just given birth to a neonate through vaginal delivery. The nurse is monitoring for signs of placental separation. Which of the following signs indicate that the placenta has separated? - ✔✔(3) Sudden gush of vaginal blood, (4) Change in shape of the uterus, (5) Lengthening of the umbilical cord
49. During labor, a client demonstrates signs of fatigue and possible fetal distress. How should the nurse intervene? - ✔✔Notify the charge nurse and prepare to assist her with necessary interventions.
50. A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? [Show Less]