4/4/25, 6:06 NR 327 exam 2 |
PM
NR 327 EXAM 2 ACTUAL QUESTIONS WITH COMPLETE
SOLUTIONS VERIFIED GRADED A++
Terms in this set (121)
When admitting a client to the labor Contraction frequency and duration
and delivery unit, which is the
priority assessment?
Six contractions in 10 minutes
The nurse is caring for a client in
labor who is receiving oxytocin.
Uterine tachysystole (hyperstimulation) is defined as more than 5
Which assessment finding requires
contractions in 10 minutes (or contractions closer than 2 minutes in
immediate action?
frequency). Tachysystole can result in decreased fetal oxygenation and
requires immediate action.
Maternal factors:premature or prolonged rupture of membranes
preeclampsia/eclampsiahistory of fetal stillbirth or demisediabetes
mellitushistory of precipitous (less than 3 hours)
What are indications for labor
laborchorioamnionitisoligohydramniospost-term gestation
induction? Select all that apply.
Fetal factors:intrauterine growth restriction (IUGR)non-reassuring fetal
heart rate and patternfetal complications, such as erythroblastosis
fetalis and hydropssignificant congenital anomalies
AROM Augmented (also called artificial) rupture of membranes
Cephalic Presentation: Fetus positioned head down; most common fetal presentation
Dilation Progressive opening of cervix caused by uterine contractions; 0-10 cm
Effacement Shortening and thinning of the cervix within stage one of labor
EFM Electronic fetal monitoring
Engagement Fetal presenting part reaches true pelvis
FHR Fetal heart rate
Fundus Upper aspect of the uterus
Intrapartum Onset of labor to birth
1/19
,4/4/25, 6:06 NR 327 exam 2 |
PM
Descent of fetal presenting part into the pelvic cavity, often 38
Lightening
weeks gestation (or 2 weeks before labor onset in primiparas)
Nonstress test; fetal assessment for well-being, (2) accelerations
NST
documented with 15 bpm above baseline × 15 seconds in length
minimum = (+) NST
Premature rupture of membranes; no contraction or no dilation
PROM
noted, but SROM occurred
SROM Spontaneous rupture of membranes
Station Relation of the presenting part to the ischial spines of maternal pelvis
Assessment performed by RN to determine cervical dilation, station,
SVE
and effacement
Dick-Read Childbirth Education focuses on alleviating the fear of
childbirth through education and the pain through relaxation and
breathing techniques. Bradley Childbirth Education teaches
Childbirth Preparation Classes
abdominal breathing to increase relaxation and emphasizes the
avoidance of medications and interventions.
Lamaze Childbirth Education teaches concentration and relaxation to
decrease contraction pain.
Fetal HR 110 and 160 bpm
During active labor the nurse should plan to monitor at least every 30 minutes.
Mild contraction tone feels soft, like the tip of the
Palpable Tone of Contractions nose. Moderate contraction tone feels like the
tightness of the chin. Strong contraction tone feels
like the forehead
If the amniotic membranes are ruptured, assess for the time of
rupture, amount, color, and odor of fluid (think of TACO). Amniotic
TACO fluid should be clear in color. A greenish color indicates that
meconium is present and a cloudy or yellow color may suggest an
infection, called chorioamnionitis. Amniotic fluid should not have a
foul or strong odor as that can also indicate a presence of infection.
Cervix is not effaced, 0 cm.
Cervix is fully effaced and dilated to 1
cm. Cervix is dilated to 5 cm.
Cervical Dilation
When the cervix is dilated to2 cm, it is the size of a penny4 cm, it is
the size of a snack cookie6 cm, it is the size of a soda can 8 cm, it is
the size of a bagel Cervix is fully dilated at 10 cm.
Vaginal exams should be performed only when necessary due to the increased risk of infection.
The nurse is caring for a laboring "How long are your contractions lasting?"
client and evaluates the "How often do you have contractions right
characteristics of contractions. now?" "When did your contractions start?"
Which questions should the nurse
ask? Select that all apply
2/19
, 4/4/25, 6:06 NR 327 exam 2 |
PM
systemic medications (meperidine, fentanyl, butorphanol, nalbuphine)
and regional pain management techniques.
Decreased fetal heart rate variability may occur after administration of
an opioid analgesic.
Medications may affect the progress and length of labor. Example:
Regional anesthesia may slow progress during the second stage of
labor by diminishing the client's urge to push.
Medications that are used in labor can make clients drowsy, so
caution should be exercised with ambulation to prevent falls.
pharmacologic pain management
options
Pregnancy complications may limit pharmacologic pain management
choices. Example: Preeclampsia may result in a low platelet count that
could prohibit the use of regional anesthesia.
Medications may have effects on pregnancy that do not occur in the
nonpregnant client. Example: High levels of natural endorphins may
modify pain perception and reduce the requirement for analgesia.
clients who abuse alcohol or illicit substances may have fewer safe
choices to manage labor pain. Example: Recent alcohol use increases
the respiratory effects of opioid anagesics.
position changes
hydrotherapy (shower, tub, or whirlpool bath)
breathing techniques (slow paced, modified paced, pattern
nonpharmacologic pain management paced) relaxation techniques (comfort, anxiety reducing
strategies, progressive relaxation, neuromuscular disassociation)
cutaneous stimulation (massage, counterpressure, warm/cool
compresses) mental stimulation (imagery, focal point)
An intrathetical anesthetic agent and opioid are used to accomplish
pain control during labor. A major adverse effect is maternal
hypotension. Rapid IV bolus infusion of lactated Ringer's or normal
Epidural
saline before initiation of the block will offset vasodilation.
Treatment includes IV fluid bolus, supplemental oxygen, and
repositioning. Phenylephrine or ephedrine may be needed to
promote vasoconstriction.
Subarachnoid injection of opioids followed by continuous pain relief
Combined Spinal-Epidural Analgesia
through an epidural catheter.
Local anesthesia: Small area of anesthesia that is used only for birth (perineal or pudendal).
A combination of 50% nitrous oxide and 50% oxygen can be used for
nitrous oxide labor pain management. Side effects include nausea, vomiting, and
dizziness. The gas mixture is self-administered by the client during
normal breathing activity.
A full bladder competes for space with the contracting uterus in the
abdominal cavity, which may cause damage to the bladder as well as
impede fetal descent and labor progress. Therefore, it is important to
assess for bladder fullness frequently and keep the client's bladder
Elimination empty during labor.
Indwelling urinary catheterization may be ordered if ambulation to the
bathroom is contraindicated, for example, when the woman has an
epidural. Bladder distention and urinary retention are common side
effects of epidural analgesia. Diarrhea in early labor is possible. Bowel
movements in the pushing phase of birth are very common due to
bearing down.
3/19
PM
NR 327 EXAM 2 ACTUAL QUESTIONS WITH COMPLETE
SOLUTIONS VERIFIED GRADED A++
Terms in this set (121)
When admitting a client to the labor Contraction frequency and duration
and delivery unit, which is the
priority assessment?
Six contractions in 10 minutes
The nurse is caring for a client in
labor who is receiving oxytocin.
Uterine tachysystole (hyperstimulation) is defined as more than 5
Which assessment finding requires
contractions in 10 minutes (or contractions closer than 2 minutes in
immediate action?
frequency). Tachysystole can result in decreased fetal oxygenation and
requires immediate action.
Maternal factors:premature or prolonged rupture of membranes
preeclampsia/eclampsiahistory of fetal stillbirth or demisediabetes
mellitushistory of precipitous (less than 3 hours)
What are indications for labor
laborchorioamnionitisoligohydramniospost-term gestation
induction? Select all that apply.
Fetal factors:intrauterine growth restriction (IUGR)non-reassuring fetal
heart rate and patternfetal complications, such as erythroblastosis
fetalis and hydropssignificant congenital anomalies
AROM Augmented (also called artificial) rupture of membranes
Cephalic Presentation: Fetus positioned head down; most common fetal presentation
Dilation Progressive opening of cervix caused by uterine contractions; 0-10 cm
Effacement Shortening and thinning of the cervix within stage one of labor
EFM Electronic fetal monitoring
Engagement Fetal presenting part reaches true pelvis
FHR Fetal heart rate
Fundus Upper aspect of the uterus
Intrapartum Onset of labor to birth
1/19
,4/4/25, 6:06 NR 327 exam 2 |
PM
Descent of fetal presenting part into the pelvic cavity, often 38
Lightening
weeks gestation (or 2 weeks before labor onset in primiparas)
Nonstress test; fetal assessment for well-being, (2) accelerations
NST
documented with 15 bpm above baseline × 15 seconds in length
minimum = (+) NST
Premature rupture of membranes; no contraction or no dilation
PROM
noted, but SROM occurred
SROM Spontaneous rupture of membranes
Station Relation of the presenting part to the ischial spines of maternal pelvis
Assessment performed by RN to determine cervical dilation, station,
SVE
and effacement
Dick-Read Childbirth Education focuses on alleviating the fear of
childbirth through education and the pain through relaxation and
breathing techniques. Bradley Childbirth Education teaches
Childbirth Preparation Classes
abdominal breathing to increase relaxation and emphasizes the
avoidance of medications and interventions.
Lamaze Childbirth Education teaches concentration and relaxation to
decrease contraction pain.
Fetal HR 110 and 160 bpm
During active labor the nurse should plan to monitor at least every 30 minutes.
Mild contraction tone feels soft, like the tip of the
Palpable Tone of Contractions nose. Moderate contraction tone feels like the
tightness of the chin. Strong contraction tone feels
like the forehead
If the amniotic membranes are ruptured, assess for the time of
rupture, amount, color, and odor of fluid (think of TACO). Amniotic
TACO fluid should be clear in color. A greenish color indicates that
meconium is present and a cloudy or yellow color may suggest an
infection, called chorioamnionitis. Amniotic fluid should not have a
foul or strong odor as that can also indicate a presence of infection.
Cervix is not effaced, 0 cm.
Cervix is fully effaced and dilated to 1
cm. Cervix is dilated to 5 cm.
Cervical Dilation
When the cervix is dilated to2 cm, it is the size of a penny4 cm, it is
the size of a snack cookie6 cm, it is the size of a soda can 8 cm, it is
the size of a bagel Cervix is fully dilated at 10 cm.
Vaginal exams should be performed only when necessary due to the increased risk of infection.
The nurse is caring for a laboring "How long are your contractions lasting?"
client and evaluates the "How often do you have contractions right
characteristics of contractions. now?" "When did your contractions start?"
Which questions should the nurse
ask? Select that all apply
2/19
, 4/4/25, 6:06 NR 327 exam 2 |
PM
systemic medications (meperidine, fentanyl, butorphanol, nalbuphine)
and regional pain management techniques.
Decreased fetal heart rate variability may occur after administration of
an opioid analgesic.
Medications may affect the progress and length of labor. Example:
Regional anesthesia may slow progress during the second stage of
labor by diminishing the client's urge to push.
Medications that are used in labor can make clients drowsy, so
caution should be exercised with ambulation to prevent falls.
pharmacologic pain management
options
Pregnancy complications may limit pharmacologic pain management
choices. Example: Preeclampsia may result in a low platelet count that
could prohibit the use of regional anesthesia.
Medications may have effects on pregnancy that do not occur in the
nonpregnant client. Example: High levels of natural endorphins may
modify pain perception and reduce the requirement for analgesia.
clients who abuse alcohol or illicit substances may have fewer safe
choices to manage labor pain. Example: Recent alcohol use increases
the respiratory effects of opioid anagesics.
position changes
hydrotherapy (shower, tub, or whirlpool bath)
breathing techniques (slow paced, modified paced, pattern
nonpharmacologic pain management paced) relaxation techniques (comfort, anxiety reducing
strategies, progressive relaxation, neuromuscular disassociation)
cutaneous stimulation (massage, counterpressure, warm/cool
compresses) mental stimulation (imagery, focal point)
An intrathetical anesthetic agent and opioid are used to accomplish
pain control during labor. A major adverse effect is maternal
hypotension. Rapid IV bolus infusion of lactated Ringer's or normal
Epidural
saline before initiation of the block will offset vasodilation.
Treatment includes IV fluid bolus, supplemental oxygen, and
repositioning. Phenylephrine or ephedrine may be needed to
promote vasoconstriction.
Subarachnoid injection of opioids followed by continuous pain relief
Combined Spinal-Epidural Analgesia
through an epidural catheter.
Local anesthesia: Small area of anesthesia that is used only for birth (perineal or pudendal).
A combination of 50% nitrous oxide and 50% oxygen can be used for
nitrous oxide labor pain management. Side effects include nausea, vomiting, and
dizziness. The gas mixture is self-administered by the client during
normal breathing activity.
A full bladder competes for space with the contracting uterus in the
abdominal cavity, which may cause damage to the bladder as well as
impede fetal descent and labor progress. Therefore, it is important to
assess for bladder fullness frequently and keep the client's bladder
Elimination empty during labor.
Indwelling urinary catheterization may be ordered if ambulation to the
bathroom is contraindicated, for example, when the woman has an
epidural. Bladder distention and urinary retention are common side
effects of epidural analgesia. Diarrhea in early labor is possible. Bowel
movements in the pushing phase of birth are very common due to
bearing down.
3/19
