ATI NSG 4525 INTRAPARTUM CORRECT EXAMS
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1.
Which of the following actions should the nurse take?
-Infuse a bolus of IV fluid.
-Administer hydralazine 25 mg IV.
-Prepare the client for immediate delivery.
-Administer betamethasone 12 mg IM. - ✔✔Administer betamethasone 12 mg IM. -
Betamethasone is classified as a corticosteroid medication. Corticosteroids are often
administered to the mother to assist in fetal lung maturity. These are usually
administered by IM injection of 12 mg for the first two doses. The subsequent dosing
should be 6 mg by IM every 12 hr x 4 doses.
✔✔A nurse on the labor and delivery unit is caring for a patient who is having induction
of labor with oxytocin administered through a secondary IV line. Uterine contractions
occur every 2 min, lasting 90 seconds, and are strong to palpation. The baseline fetal
heart rate is 150/min, with a uniform deceleration beginning at the peak of the
contraction and a return to baseline after the contractions is over. Which of the following
actions should the nurse take?--Decrease the rate of infusion of the maintenance IV
solution
-Discontinue the infusion of the IV oxytocin
-Increase the rate of infusion of the IV oxytocin
-Slow the client's rate of breathing - ✔✔Discontinue the infusion of the IV oxytocin. -
Discontinue the oxytocin infusion immediately if a client is experiencing late
decelerations due to uterine hyperstimulation.
✔✔A nurse in the emergency department is admitting a client who is at 40 weeks of
gestation, has reptured membranes, and the nurse observes the newborn's head is
crowning. the client tells the nurse she wants to push. Which of the following statements
should the nurse make?
-"You should go ahead and push to assist the delivery."
-"You should try to pant as the delivery proceeds."
-"You should try to perform slow-paced breathing."
, -"You should take a deep, cleansing breath and breathe naturally." - ✔✔"You should try
to pant as the delivery proceeds." -
Panting allows uterine forces to expel the fetus and permits controlled muscle
expansion to avoid rapid expulsion of the fetal head.
✔✔A nurse is caring for a client who is in labor and assists the provider who performs
an amniotomy. Which of the following is the priority action by the nurse following the
procedure?
-Monitor the client's temperature.
-Assess the fetal heart rate.
-Assess the odor of the amniotic fluid.
-Provide clean, dry underpads. - ✔✔Assess the fetal heart rate.-
The fetal heart rate should be assessed before and immediately after the amniotomy to
detect any changes.
✔✔A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal
head is at 3+ station after a vagina exam. Which I the following actions should the nurse
take?
-Apply fundal pressure.
-Observe for the presence of a nuchal cord.
-Observe for crowning.
-Prepare to administer oxytocin. - ✔✔Observe for crowning.-
In the descent phase of the second stage of labor, crowning occurs when the fetal head
is at +2 to +4 station. Because this is the client's third childbirth experience, it is
reasonable to assume that delivery is imminent.
✔✔A nurse is caring for a client who is a primigravida, at term, and having contractions
but is stating that she is "not really sure if she is in labor or not." Which of the following
should the nurse recognize as a sign of true labor?
-Rupture of the membranes
-Changes in the cervix
-Station of the presenting part
-Pattern of contractions - ✔✔Changes in the cervix -
Assessment of progressive changes in the effacement and dilation of the cervix is the
most accurate indication of true labor.
✔✔A nurse is caring for a client who is in the first stage of labor, undergoing external
fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the
fetal heart rate on the monitor strip. Which of the following is a correct interpretation of
this finding?
-Variable decelerations are due to umbilical cord compression.
-Variable decelerations are caused by uteroplacental insufficiency.
-Variable decelerations are a result of the administration of IV narcotic analgesics.
-Variable decelerations are related to fetal head compression. - ✔✔Variable
decelerations are due to umbilical cord compression. -
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1.
Which of the following actions should the nurse take?
-Infuse a bolus of IV fluid.
-Administer hydralazine 25 mg IV.
-Prepare the client for immediate delivery.
-Administer betamethasone 12 mg IM. - ✔✔Administer betamethasone 12 mg IM. -
Betamethasone is classified as a corticosteroid medication. Corticosteroids are often
administered to the mother to assist in fetal lung maturity. These are usually
administered by IM injection of 12 mg for the first two doses. The subsequent dosing
should be 6 mg by IM every 12 hr x 4 doses.
✔✔A nurse on the labor and delivery unit is caring for a patient who is having induction
of labor with oxytocin administered through a secondary IV line. Uterine contractions
occur every 2 min, lasting 90 seconds, and are strong to palpation. The baseline fetal
heart rate is 150/min, with a uniform deceleration beginning at the peak of the
contraction and a return to baseline after the contractions is over. Which of the following
actions should the nurse take?--Decrease the rate of infusion of the maintenance IV
solution
-Discontinue the infusion of the IV oxytocin
-Increase the rate of infusion of the IV oxytocin
-Slow the client's rate of breathing - ✔✔Discontinue the infusion of the IV oxytocin. -
Discontinue the oxytocin infusion immediately if a client is experiencing late
decelerations due to uterine hyperstimulation.
✔✔A nurse in the emergency department is admitting a client who is at 40 weeks of
gestation, has reptured membranes, and the nurse observes the newborn's head is
crowning. the client tells the nurse she wants to push. Which of the following statements
should the nurse make?
-"You should go ahead and push to assist the delivery."
-"You should try to pant as the delivery proceeds."
-"You should try to perform slow-paced breathing."
, -"You should take a deep, cleansing breath and breathe naturally." - ✔✔"You should try
to pant as the delivery proceeds." -
Panting allows uterine forces to expel the fetus and permits controlled muscle
expansion to avoid rapid expulsion of the fetal head.
✔✔A nurse is caring for a client who is in labor and assists the provider who performs
an amniotomy. Which of the following is the priority action by the nurse following the
procedure?
-Monitor the client's temperature.
-Assess the fetal heart rate.
-Assess the odor of the amniotic fluid.
-Provide clean, dry underpads. - ✔✔Assess the fetal heart rate.-
The fetal heart rate should be assessed before and immediately after the amniotomy to
detect any changes.
✔✔A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal
head is at 3+ station after a vagina exam. Which I the following actions should the nurse
take?
-Apply fundal pressure.
-Observe for the presence of a nuchal cord.
-Observe for crowning.
-Prepare to administer oxytocin. - ✔✔Observe for crowning.-
In the descent phase of the second stage of labor, crowning occurs when the fetal head
is at +2 to +4 station. Because this is the client's third childbirth experience, it is
reasonable to assume that delivery is imminent.
✔✔A nurse is caring for a client who is a primigravida, at term, and having contractions
but is stating that she is "not really sure if she is in labor or not." Which of the following
should the nurse recognize as a sign of true labor?
-Rupture of the membranes
-Changes in the cervix
-Station of the presenting part
-Pattern of contractions - ✔✔Changes in the cervix -
Assessment of progressive changes in the effacement and dilation of the cervix is the
most accurate indication of true labor.
✔✔A nurse is caring for a client who is in the first stage of labor, undergoing external
fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the
fetal heart rate on the monitor strip. Which of the following is a correct interpretation of
this finding?
-Variable decelerations are due to umbilical cord compression.
-Variable decelerations are caused by uteroplacental insufficiency.
-Variable decelerations are a result of the administration of IV narcotic analgesics.
-Variable decelerations are related to fetal head compression. - ✔✔Variable
decelerations are due to umbilical cord compression. -
