Labor & Delivery Saunders NCLEX
questions 80Qwexp(Latest Exam 2024)
The nurse in a maternity unit is reviewing the clients'
records. Which client would the nurse identify as being at
the most risk for developing disseminated intravascular
coagulation?
1.
A primigravida with mild preeclampsia
2.
A primigravida who delivered a 10-lb infant 3 hours ago
3.
A gravida II who has just been diagnosed with dead fetus
syndrome
4.
A gravida IV who delivered 8 hours ago and has lost 500
mL of blood -correct answers✅3
In a pregnant client, disseminated intravascular
coagulation (DIC) is a condition in which the clotting
cascade is activated, resulting in the formation of clots in
the microcirculation. Dead fetus syndrome is considered a
risk factor for DIC. Severe preeclampsia is considered a
risk factor for DIC; a mild case is not. Delivering a large
,Labor & Delivery Saunders NCLEX
questions 80Qwexp(Latest Exam 2024)
newborn is not considered a risk factor for DIC.
Hemorrhage is a risk factor for DIC; however, a loss of
500 mL is not considered hemorrhage.
he nurse is caring for a client in labor. Which assessment
finding indicates to the nurse that the client is beginning
the second stage of labor?
1.
The contractions are regular.
2.
The membranes have ruptured.
3.
The cervix is dilated completely.
4.
The client begins to expel clear vaginal fluid. -correct
answers✅3.
The second stage of labor begins when the cervix is
dilated completely and ends with birth of the neonate.
,Labor & Delivery Saunders NCLEX
questions 80Qwexp(Latest Exam 2024)
Options 1, 2, and 4 are not specific assessment findings
of the second stage of labor and occur in stage 1.
The nurse in the labor room is caring for a client in the
active stage of the first phase of labor. The nurse is
assessing the fetal patterns and notes a late deceleration
on the monitor strip. What is the most appropriate
nursing action?
1.
Administer oxygen via face mask.
2.
Place the mother in a supine position.
3.
Increase the rate of the oxytocin (Pitocin) intravenous
infusion.
4.
Document the findings and continue to monitor the fetal
patterns. -correct answers✅1
, Labor & Delivery Saunders NCLEX
questions 80Qwexp(Latest Exam 2024)
Late decelerations are due to uteroplacental insufficiency
and occur because of decreased blood flow and oxygen to
the fetus during the uterine contractions. Hypoxemia
results; oxygen at 8 to 10 L/minute via face mask is
necessary. The supine position is avoided because it
decreases uterine blood flow to the fetus. The client
should be turned onto her side to displace pressure of the
gravid uterus on the inferior vena cava. An intravenous
oxytocin infusion is discontinued when a late deceleration
is noted. The oxytocin would cause further hypoxemia
because of increased uteroplacental insufficiency
resulting from stimulation of contractions by this
medication. Although the nurse would document the
occurrence, option 4 would delay necessary treatment.
The nurse is performing an assessment of a client who is
scheduled for a cesarean delivery. Which assessment
finding would indicate the need to contact the health care
provider?
1.
Hemoglobin of 11 g/dL
2.
Fetal heart rate of 180 beats/minute
questions 80Qwexp(Latest Exam 2024)
The nurse in a maternity unit is reviewing the clients'
records. Which client would the nurse identify as being at
the most risk for developing disseminated intravascular
coagulation?
1.
A primigravida with mild preeclampsia
2.
A primigravida who delivered a 10-lb infant 3 hours ago
3.
A gravida II who has just been diagnosed with dead fetus
syndrome
4.
A gravida IV who delivered 8 hours ago and has lost 500
mL of blood -correct answers✅3
In a pregnant client, disseminated intravascular
coagulation (DIC) is a condition in which the clotting
cascade is activated, resulting in the formation of clots in
the microcirculation. Dead fetus syndrome is considered a
risk factor for DIC. Severe preeclampsia is considered a
risk factor for DIC; a mild case is not. Delivering a large
,Labor & Delivery Saunders NCLEX
questions 80Qwexp(Latest Exam 2024)
newborn is not considered a risk factor for DIC.
Hemorrhage is a risk factor for DIC; however, a loss of
500 mL is not considered hemorrhage.
he nurse is caring for a client in labor. Which assessment
finding indicates to the nurse that the client is beginning
the second stage of labor?
1.
The contractions are regular.
2.
The membranes have ruptured.
3.
The cervix is dilated completely.
4.
The client begins to expel clear vaginal fluid. -correct
answers✅3.
The second stage of labor begins when the cervix is
dilated completely and ends with birth of the neonate.
,Labor & Delivery Saunders NCLEX
questions 80Qwexp(Latest Exam 2024)
Options 1, 2, and 4 are not specific assessment findings
of the second stage of labor and occur in stage 1.
The nurse in the labor room is caring for a client in the
active stage of the first phase of labor. The nurse is
assessing the fetal patterns and notes a late deceleration
on the monitor strip. What is the most appropriate
nursing action?
1.
Administer oxygen via face mask.
2.
Place the mother in a supine position.
3.
Increase the rate of the oxytocin (Pitocin) intravenous
infusion.
4.
Document the findings and continue to monitor the fetal
patterns. -correct answers✅1
, Labor & Delivery Saunders NCLEX
questions 80Qwexp(Latest Exam 2024)
Late decelerations are due to uteroplacental insufficiency
and occur because of decreased blood flow and oxygen to
the fetus during the uterine contractions. Hypoxemia
results; oxygen at 8 to 10 L/minute via face mask is
necessary. The supine position is avoided because it
decreases uterine blood flow to the fetus. The client
should be turned onto her side to displace pressure of the
gravid uterus on the inferior vena cava. An intravenous
oxytocin infusion is discontinued when a late deceleration
is noted. The oxytocin would cause further hypoxemia
because of increased uteroplacental insufficiency
resulting from stimulation of contractions by this
medication. Although the nurse would document the
occurrence, option 4 would delay necessary treatment.
The nurse is performing an assessment of a client who is
scheduled for a cesarean delivery. Which assessment
finding would indicate the need to contact the health care
provider?
1.
Hemoglobin of 11 g/dL
2.
Fetal heart rate of 180 beats/minute
