NURS 1102 Passpoint-Intrapartum {Revised} – Fairleigh Dickinson University | NURS1102 Passpoint - Intrapartum {A Grade}

NURS 1102 Passpoint-Intrapartum – Fairleigh Dickinson University 100+ of Questions and answers Question 1 See full question A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean birth may be necessary? You Selected: • Maternal heart rate of 65 beats/minute Correct response: • Fetal heart rate of 80 beats/minute Explanation: Remediation: Question 2 See full question A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? You Selected: • The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff Correct response: • The chaplain, because his educational background includes strategies for handling griefExplanation: Remediation: Question 3 See full question A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for: You Selected: • hypotension. Correct response: • hypotension. Explanation: Remediation: Question 4 See full question The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? You Selected: • umbilical cord Correct response: • umbilical cord Explanation: Remediation: Question 5 See full questionThe membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding? You Selected: • maternal intrauterine infection Correct response: • passage of meconium by the fetus Explanation: Remediation: Question 6 See full question Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks’ gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be mostappropriate? You Selected: • Give the client a paper bag and have her breathe into it. Correct response: • Give the client a paper bag and have her breathe into it. Explanation: Remediation: Question 7 See full question A client had a cesarean section with her first pregnancy and is hoping to have a vaginal birth with this pregnancy. She begins to cry at her 38-week visit when she realizes that her baby is a breech presentation. She says, “I just know it’s going to be horrible again. I won’t be able to breastfeed my baby. It will be painful.” Which of the following responses from the nurse is appropriate?You Selected: • “Tell me about your previous baby’s birth.” Correct response: • “Tell me about your previous baby’s birth.” Explanation: Remediation: Question 8 See full question The nurse is caring for a pregnant client. The nurse notes hypotension and a nonreassuring fetal heart tracing. Which of the following would the nurse include in the client’s plan of care? You Selected: • Call the healthcare provider Correct response: • Position the client on her left side Explanation: Remediation: Question 9 See full question A nurse is evaluating the external fetal monitoring strip (see image) of a client who is in labor. Which nursing interventions would the nurse implement? You Selected: • Reassure the client and continue to monitor the fetal heart rate. Correct response: • Reassure the client and continue to monitor the fetal heart rate. Explanation:Remediation: Question 10 See full question The nurse is performing Leopold’s maneuvers to determine fetal presentation and position. Which illustration shows the third maneuver? You Selected: • Correct response:• Explanation: Question 1 See full question Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently? You Selected: • Alterations in cardiovascular function affect the fetus. Correct response: • Alterations in cardiovascular function affect the fetus. Explanation: Remediation: Question 2 See full question A 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? You Selected: • Change the client's position.Correct response: • Change the client's position. Explanation: Remediation: Question 3 See full question While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? You Selected: • Duration, frequency, and intensity Correct response: • Duration, frequency, and intensity Explanation: Remediation: Question 4 See full question What should the nurse include in the plan of care for a client with diabetes who is in labor? You Selected: • Administer insulin subcutaneously every 4 hours. Correct response: • Monitor blood glucose levels every hour. Explanation: Remediation: Question 5 See full questionA laboring client on oxyitocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings, which of the following would be the best action for the nurse? You Selected: • Continue the oxytocin until uterine contractions are more frequent than every 2- 3 minutes. Correct response: • Discontinue the oxytocin if the uterus does not relax between uterine contractions. Explanation: Remediation: Question 6 See full question A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client’s temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time? You Selected: • Ask the client what fluids she prefers to drink. Correct response: • Ask the client what fluids she prefers to drink. Explanation: Remediation: Question 7 See full questionA couple arrives at the hospital stating that the client’s contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse’s first priority while performing the admission? You Selected: • Ensure that the client will have a support person in labor. Correct response: • Assess the imminence of birth. Explanation: Remediation: Question 8 See full question A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if he/she is allowed to perform this skill. What is the nurse’s most appropriate response? You Selected: • "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first." Correct response: • "Yes, but I will demonstrate it once and then supervise you while you perform the procedure." Explanation: Remediation: Question 9 See full question A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority?You Selected: • Uterine massage Correct response: • Uterine massage Explanation: Remediation: Question 10 See full question The nurse who is assessing the position, presentation, and lie of the fetus of a 9-monthpregnant woman performs which of the following actions? You Selected: • Leopold's maneuvers Correct response: • Leopold's maneuvers Question 1 See full question A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth? You Selected: • Umbilical cord prolapse Correct response: • Umbilical cord prolapse Explanation: Remediation: Question 2 See full questionA client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has oxytocin infusing. Which response by the nurse is best? You Selected: • "You may use the bathroom with my assistance." Correct response: • "You may use the bathroom with my assistance." Explanation: Remediation: Question 3 See full question A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to: You Selected: • the social worker on call. Correct response: • the social worker on call. Explanation: Remediation: Question 4 See full question The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time? You Selected:• lying in the left lateral recumbent position Correct response: • walking around in the hallway Explanation: Remediation: Question 5 See full question What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia? You Selected: • offering encouragement and support Correct response: • offering encouragement and support Explanation: Remediation: Question 6 See full question A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks’ gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks’ gestation. What nursing action would be the highest priority for this client? You Selected: • Assess maternal contraction and fetal heart rate pattern. Correct response: • Assess maternal contraction and fetal heart rate pattern.Explanation: Remediation: Question 7 See full question A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first: You Selected: • complete a vaginal examination to determine dilation, effacement, and station. Correct response: • complete a vaginal examination to determine dilation, effacement, and station. Explanation: Remediation: Question 8 See full question The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. Which of the following interventions should the nurse include in the client’s plan of care? You Selected: • Calling the healthcare provider Correct response: • Repositioning the client on her side Explanation: Question 9 See full question The nurse is caring for a client in labor. Which of the following is how the nurse would report the frequency of each contraction?You Selected: • Measuring the length of time from the start of one contraction to the start of the next Correct response: • Measuring the length of time from the start of one contraction to the start of the next Explanation: Remediation: Question 10 See full question The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? You Selected: • use of protective goggles during a caesarean birth Correct response: • wearing of sterile gloves to bathe a neonate at 2 hours of age Question 1 See full question A client at 36 weeks' gestation is admitted in preterm labor with a temperature of 101.2° F (38.4° C). She reports a steady dripping from the vaginal area and examination indicates that she's leaking amniotic fluid. A nurse realizes the probable cause of her fever is: You Selected: • a normal response to labor. Correct response: • intrauterine infection.Explanation: Remediation: Question 2 See full question A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby is coming!" To help the client remain calm and cooperative during the imminent birth, which response by the nurse is most appropriate? You Selected: • "I will explain what is happening to guide you as we go along." Correct response: • "I will explain what is happening to guide you as we go along." Explanation: Remediation: Question 3 See full question When preparing a multigravid client at 34 weeks’ gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal systems? You Selected: • urinary Correct response: • pulmonary Explanation: Remediation: Question 4 See full questionThe nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section? You Selected: • client at 38 weeks' gestation with active herpes lesions - - - - - - - - Continued