Labor & Delivery Saunders NCLEX
questions and answers
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 - ....🔰
VERIFIED 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 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. - ....🔰VERIFIED ANSWERS....
✔✔3.
The second stage of labor begins when the cervix is dilated completely and
ends with birth of the neonate. 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. - ....🔰
VERIFIED ANSWERS.... ✔✔1
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
3.
Maternal pulse rate of 85 beats/minute
4.
White blood cell count of 12,000 cells/mm3 - ....🔰VERIFIED ANSWERS....
✔✔2
A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180
beats/minute could indicate fetal distress and would warrant immediate
notification of the HCP. By full term, a normal maternal hemoglobin range is
11 to 13 g/dL because of the hemodilution caused by an increase in plasma
volume during pregnancy. The maternal pulse rate during pregnancy increases
10 to 15 beats/minute over prepregnancy readings to facilitate increased
cardiac output, oxygen transport, and kidney filtration. White blood cell counts
in a normal pregnancy begin to increase in the second trimester and peak in
the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to
18,000 cells/mm3). During the immediate postpartum period, the white blood
cell count may be 25,000 to 30,000 cells/mm3 because of increased leukocytosis
that occurs during delivery.
questions and answers
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 - ....🔰
VERIFIED 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 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. - ....🔰VERIFIED ANSWERS....
✔✔3.
The second stage of labor begins when the cervix is dilated completely and
ends with birth of the neonate. 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. - ....🔰
VERIFIED ANSWERS.... ✔✔1
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
3.
Maternal pulse rate of 85 beats/minute
4.
White blood cell count of 12,000 cells/mm3 - ....🔰VERIFIED ANSWERS....
✔✔2
A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180
beats/minute could indicate fetal distress and would warrant immediate
notification of the HCP. By full term, a normal maternal hemoglobin range is
11 to 13 g/dL because of the hemodilution caused by an increase in plasma
volume during pregnancy. The maternal pulse rate during pregnancy increases
10 to 15 beats/minute over prepregnancy readings to facilitate increased
cardiac output, oxygen transport, and kidney filtration. White blood cell counts
in a normal pregnancy begin to increase in the second trimester and peak in
the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to
18,000 cells/mm3). During the immediate postpartum period, the white blood
cell count may be 25,000 to 30,000 cells/mm3 because of increased leukocytosis
that occurs during delivery.
