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1.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?
A.The client begins to expel clear vaginal fluid
B.The contractions are regular
C.The membranes have ruptured
D.The cervix is dilated completely
1.4. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.
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:
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion
3. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
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?
1.Fetal heart rate of 180 beats per minute
2.White blood cell count of 12,000
3.Maternal pulse rate of 85 beats per minute
4.Hemoglobin of 11.0 g/dL
1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.
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:
1.Trendelenburg's position with the legs in stirrups
2.Semi-Fowler position with a pillow under the knees
3.Prone position with the legs separated and elevated
4.Supine position with a wedge under the right hip
4. Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus.
. 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:
1.Noting if the heart rate is greater than 140 BPM
2.Placing the diaphragm of the Doppler on the mother abdomen
3.Performing Leopold's maneuvers first to determine the location of the fetal heart
4.Palpating the maternal radial pulse while listening to the fetal heart rate
4. The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.
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?
1.Three contractions occurring within a 10-minute period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated between contractions
4.Increased urinary output
2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.
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?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.
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?
1.Encourage the client's coach to continue to encourage breathing exercises
2.Encourage the client to continue pushing with each contraction
3.Continue monitoring the fetal heart rate
4.Notify the physician or nurse mid-wife
4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified.
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?
1.Document the findings and tell the mother that the monitor indicates fetal well-being
2.Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen.
3.Notify the physician or nurse mid-wife of the findings.
4.Reposition the mother and check the monitor for changes in the fetal tracing
1. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.
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.Identifying the types of accelerations
2.Assessing the baseline fetal heart rate
3.Determining the frequency of the contractions
4.Determining the intensity of the contractions
2. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur.
Options 1 and 3 are important to assess, but not as the first priority.
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:
1.1 cm above the ischial spine
2.1 fingerbreadth below the symphysis pubis
3.1 inch below the coccyx
4.1 inch below the iliac crest
1. Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines.
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?
1.A loud mouth
4. Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Having a loud mouth is only related to the person typing up this test.
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:
4. As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
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:
1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal blood pressure monitoring
2. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
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?
2. Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.
A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is:
1.A form of biofeedback to enhance bearing down efforts during delivery
2.Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus
3.The application of pressure to the sacrum to relieve a backache
4.Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest
2. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.
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:
2.Fear of losing control
2. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor.
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.
1.Stop of Pitocin infusion
2.Perform a vaginal examination
3.Reposition the client
4.Check the client's blood pressure and heart rate
5.Administer oxygen by face mask at 8 to 10 L/min
1, 4, 2. 5, 3.
If uterine hypertonicity occurs, the nurse immediately would intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord
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?
1.Medication that will provide sedation
3.Oxytocin (Pitocin) infusion
4.Administration of a tocolytic medication
3. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.
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:
1.Monitor the Pitocin infusion closely
2.Provide pain relief measures
3.Prepare the client for an amniotomy
4.Promote ambulation every 30 minutes
2. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.
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?
1.Keeping the significant other informed of the progress of the labor
2.Providing comfort measures
3.Monitoring fetal heart rate
4.Changing the client's position frequently
3. The priority is to monitor the fetal heart rate.
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:
1.Over the fetus that is most anterior to the mothers abdomen
2.Over the fetus that is most posterior to the mothers abdomen
3.So that each fetal heart rate is monitored separately
4.So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus
3. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.
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?
1.Disseminated intravascular coagulation
4. Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.
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?
1.The umbilical cord shortens in length and changes in color
2.A soft and boggy uterus
3.Maternal complaints of severe uterine cramping
4.Changes in the shape of the uterus
4. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vagina), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping. I am going to look more into this answer. According to our book on page 584, this is not one of our options.
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?
1.Place the client in Trendelenburg's position
2.Call the delivery room to notify the staff that the client will be transported immediately
3.Gently push the cord into the vagina
4.Find the closest telephone and stat page the physician
1. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
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?
1.Swelling of the calf in one leg
2.Prolonged clotting times
3.Decreased platelet count
4.Petechiae, oozing from injection sites, and hematuria
1. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophebitis.
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?
1.Absence of abdominal pain
2.A soft abdomen
4.Painless, bright red vaginal bleeding
3. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict blood vessels and control bleeding.
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?
1.Prepare the client for an ultrasound
2.Obtain equipment for external electronic fetal heart monitoring
3.Obtain equipment for a manual pelvic examination
4.Prepare to draw a Hgb and Hct blood sample
3. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia
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:
1.Complete bed rest for the remainder of the pregnancy
2.Delivery of the fetus
3.Strict monitoring of intake and output
4.The need for weekly monitoring of coagulation studies until the time of delivery
2. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.
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?
4.Weak bearing down efforts
2. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be:
1.Auscultating the fetal heart
2.Taking an obstetric history
3.Asking the client when she last ate
4.Ascertaining whether the membranes were ruptured
1. Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.
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:
1.Not yet engaged
2.Entering the pelvic inlet
3.Below the ischial spines
4.Visible at the vaginal opening
3. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
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:
1.Above the umbilicus at the midline
2.Above the umbilicus on the left side
3.Below the umbilicus on the right side
4.Below the umbilicus near the left groin
3. Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.
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:
1.Until the time it is completely over
2.To the end of a second contraction
3.To the beginning of the next contraction
4.Until the time that the uterus becomes very firm
3. This is the way to determine the frequency of the contractions
The nurse observes the client's amniotic fluid and decides that it appears normal, because it is:
1.Clear and dark amber in color
2.Milky, greenish yellow, containing shreds of mucus
3.Clear, almost colorless, and containing little white specks
4.Cloudy, greenish-yellow, and containing little white specks
3. by 36 weeks' gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.
At 38 weeks' gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:
1.Discontinue the catheter, if the reading is not above 80%
2.Discontinue the catheter, if the reading does not go below 30%
3.Advance the catheter until the reading is above 90% and continue monitoring
4.Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
4. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.
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:
1.Stop the oxytocin infusion
2.Change the client's position
3.Prepare for immediate delivery
4.Take the client's blood pressure
2. Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.
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:
2.An early elevation
3.A sonographic motion
4.A tachycardic heart rate
1. An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:
4. A persistent occiput-posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.
The breathing technique that the mother should be instructed to use as the fetus' head is crowning is:
1. Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.
During the period of induction of labor, a client should be observed carefully for signs of:
4.Umbilical cord prolapse
2. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
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