NURS 1023 Intrapartum Period LWW Questions & Answers

NURS 1023 Intrapartum Period LWW During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. 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? Correct response: • Contractions will be stronger and more uncomfortable and will peak more abruptly. The nurse is preparing to admit a client who came to the delivery area in the company of her husband. The client states, "I am in labor and I attended the facility clinic for prenatal care." Which question should the nurse ask her first? Correct response: • "What is your expected due date?" A diabetic client in labor tells the nurse she has been feeling nauseous since her labor started and did not take her insulin even after eating some soup and crackers. One hour later, she reports increased nausea and feeling flushed. The nurse notes a fruity odor to her breath. What do these findings suggest? Correct response: • Diabetic ketoacidosis Which care intervention is appropriate for the fourth stage of labor? Correct response: • Assessing lochia and the location and consistency of the fundus Which of the following health conditions makes it necessary for the nurse to check blood pressure frequently during labor? Correct response: • Preeclampsia The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? Correct response: • Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered. A client in the early stage of labor states that she has a thick, yellow discharge from both of her breasts. Which action by the nurse is most appropriate? Correct response: • Informing the client that the discharge is colostrum, which is a normal finding 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? Correct response: • Ask the husband to leave or phone security. A nurse caring for a client in labor notes a fetal heart rate of 170 and meconium stained amniotic fluid. What priority action should the nurse take? Correct response: • Notify the health care provider. A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take? Correct response: • Reposition the client to left lateral position. 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? Correct response: • Assisting the client to ambulate in the room A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client’s history, which finding would the nurse identify as placing the client at increased risk for fetal distress? Correct response: • blood pressure of 146/94 mm Hg A client concerned about the pinkish “stretch marks” on her abdomen asks the nurse about them. Which response by the nurse would be most appropriate? Correct response: • “Although they will fade, they won’t disappear.” A nurse is caring for a client in labor diagnosed with active genital herpes. Which actions should the nurse anticipate? Select all that apply. Correct response: • cesarean birth • witness consent for surgery A nurse is reviewing data for multiple clients in the first stage of labor. Which client should receive priority attention? Correct response: • a client with blood pressure of 160/90, pulse 92, respiration 22, temperature 99.1, and positive proteinuria A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply. Correct response: • Check vital signs. • Check the fundal height. • Notify the RN. A client who is induced at 40 weeks' gestation with oxytocin drip is expressing fear and anxiety about the induced labor. Which interventions should the nurse implement? Select all that apply. Correct response: • Establish trust with the client. • Explore the client's coping behaviors. • Keep client informed about progress and procedures. A primigravida client is admitted to the labor and birth unit in labor. She is 2 cm dilated and 50% effaced, and the fetal head is at 0 station. The client is having moderately strong contractions, lasting about 40 seconds, every 5 minutes. She seems anxious and becomes very tense during each contraction. When the client asks for pain relief, what should the nurse do next? Correct response: • Determine the source of the client's anxiety, and implement interventions to help her relax. A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client’s chart (shown), into which position should the nurse assist the client? Correct response: • left lateral A client in labor, who attended natural birth classes, is asking for something to relieve the pain. What is the most appropriate action for the nurse to take? Correct response: • Contact the health care provider, supporting the client until an analgesic is prescribed. The third stage of labor ends after the birth of the placenta. Which action should the nurse take immediately following the birth of the placenta? Correct response: • Examine the placenta for completeness. A client in labor is prescribed oxytocin and asks the nurse, “What’s this medication for?” The nurse would incorporate wledge of which action in the response? Correct response: • stimulates labor and prevents hemorrhage The nurse instructs a client in labor to change position frequently to promote comfort and prevent complications. Which complication is likely to occur with the client in supine position? Select all that apply. Correct response: • maternal hypotension • fetal hypoxia A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has an intravenous infusion of oxytocin running. Which response by the nurse would be best? Correct response: • "You may use the bathroom with my assistance." A nurse is caring for a client in the fourth stage of labor. Based on the nurse’s note, which postpartum complication has the client developed? Correct response: • postpartum hemorrhage A pregnant client is at term and in labor. The nurse is checking the fetal heart rate. Which finding would the nurse interpret as indicating appropriate fetal perfusion? Correct response: • 135 beats/minute The nurse places a client in labor in a supine position to obtain a good monitor tracing when suddenly, the client becomes light-headed and diaphoretic. Which of the following should be the nurse's first action? Correct response: • Reposition the client to her left side. A client gives birth to a 9-lb, 10-oz (4.4-kg) neonate vaginally, with a midline episiotomy. Shortly after birth, the client reports to a nurse that she is not feeling well. In monitoring the client for possible uterine hemorrhage, the nurse should report which findings? Correct response: • cool, clammy, pale skin and anxiety A client who's in labor and who attended natural childbirth classes is asking for something for pain. What should the nurse do? Correct response: • Contact the physician and support the client until something can be ordered for pain. 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 take which of the following actions? Correct response: • Notify the obstetrician A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. Which type of birth should the nurse anticipate for this client? Correct response: • Cesarean A 23-year-old primigravida client is in the active stage of labor. She and her husband have been using breathing techniques. The husband asks whether he can do anything more to help his wife during labor. What should the nurse suggest? Correct response: • Provide helpful distractions. A client in the first stage of labor is agitated, upset, and crying. The client expressed concern about being in labor for 32 hours the last time she gave birth. Based on this information, the nurse should expect which nursing diagnosis in the client's plan of care? Correct response: • Fear related to a potentially difficult childbirth A client comes to the labor unit reporting contractions. After gathering data, it is determined the client is having Braxton Hicks contractions, and education regarding the difference between true and false labor is given. Which statement by the client indicates the teaching has been effective? Correct response: • “Braxton Hicks contractions begin in the abdomen and remain irregular.” A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion? Correct response: • 42 drops/minute 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? Correct response: • Instruct the husband on touch, massage, and breathing patterns. The nurse is assisting in the delivery of a client with precipitate labor. After the delivery of the head, which actions should the nurse take to ensure safety of the mother and baby? Select all that apply. Correct response: • Suction infant's mouth then nose with bulb syringe. • Check around neck for possible tight umbilical cord. • Support perineum with a sterile towel as the head is crowning. A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response? Correct response: • Explain to the client that the feeling is normal during this stage. A nurse is collecting data from a client in labor and suspects that the client may have been physically abused by her male partner. Which intervention by the nurse would be most appropriate? Correct response: • Collaborate with the health care provider to make a referral to social services. The nurse-midwife determines that a client is in the second stage of labor and the presenting part is descending rapidly. What action should the nurse take to prevent complications? Correct response: • Encourage the client to practice breathing exercises to decrease the urge to push. A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in the fetal heart rate (FHR). After notifying the registered nurse in charge, what should the nurse do next? Correct response: • Change the client's position. A nurse is caring for a primigravida client who is in labor. When does the nurse suspect the client has progressed to the second stage of labor? Correct response: • Client has an uncontrollable urge to bear down. A multiparous client admitted to the labor unit has not received prenatal care for this pregnancy. When collecting information from this client, which data would be most important to obtain? Correct response: • date of last menstrual period (LMP) A client in labor is receiving magnesium sulfate as an intravenous infusion. Which medication should the nurse ensure is at the bedside while the magnesium sulfate is being infused? Correct response: • calcium gluconate A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion? Correct response: • Fetal heart rate variability within an acceptable range A client is to have an epidural block to relieve labor pain. Her blood pressure is noted to be 90/60 mmHg. What should the nurse do? Correct response: • Notify the anesthesiologist. A multiparous client in labor is 5 cm dilated and requesting pain medication. The nurse administered an opioid analgesia. After 15 minutes, the client expresses the urge to bear down. What should the nurse do first? Correct response: • Perform vaginal examination to determine cervical dilatation. A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next? Correct response: • Massage the fundus. A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding? Correct response: • fetal heart rate of 80 beats/minute The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? Correct response: • Change the client's position. The nurse caring for a primipara in late first stage of labor notes left occipito- anterior (LOA) position, 7 cm dilated, and at +2 station. Which finding should be reported to the health care provider? Correct response: • Labor is progressing well. When caring for a client during the second stage of labor, which action would be most appropriate? Correct response: • Assisting the mother with pushing The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN? Correct response: • A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit. 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? Correct response: • Ask the husband to leave or phone security. A nurse caring for a client in labor notes a fetal heart rate of 170 and meconium stained amniotic fluid. What priority action should the nurse take? Correct response: • Notify the health care provider. A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take? Correct response: • Reposition the client to left lateral position. Which intervention should be included in the safety plan for the maternal- infant unit? Correct response: • Making sure that the spouse or significant other wears an identification band A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client’s history, which finding