NCLEX - MATERNITY NURSING: INTRAPARTUM

1. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. Increased urinary output C. Adequate resting tone of the uterus palpated between contractions D. A fetal heart rate of 90 beats per minute 2. A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? A. Placing the client on complete bed rest B. Continuous electronic fetal monitoring C. An IV infusion of antibiotics D. Placing a code cart at the client’s bedside 3. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? A. Encourage the client’s coach to continue to encourage breathing exercises. B. Encourage the client to continue pushing with each contraction. C. Continue monitoring the fetal heart rate. D. Notify the physician or nurse-midwife. 4. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being. B. Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen. C. Notify the physician or nurse-midwife of the findings. D. Reposition the mother and check the monitor for changes in the fetal tracing.