NCLEX Labor & Delivery

NCLEX Labor & Delivery A nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage? - Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg A client in the first stage of labor is being monitored using an external fetal monitor. A nurse notes variable decelerations on the monitoring strip. Into what position should the nurse assist the client? - lateral 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. Who should the nurse manager consult to help the staff cope with this unexpected death? 1. The human resource director, so she can arrange vacation time for the staff 2. The physician, so he can provide education about HELLP syndrome 3. The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff 4. The chaplain, because his educational background includes strategies for handling grief - Answer: 4 RATIONALES: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate. Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients? - The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change from slow chest breathing to which breathing technique? a) deep chest breathing b) rapid pant-blow breathing c) slow abdominal breathing d) rapid, shallow chest breathing - Rapid, shallow chest breathing The psychoprophylaxis method of childbirth suggests using slow chest breathing until it becomes ineffective during labor contractions, then switching to shallow chest breathing (mostly at the sternum) during the peak of a contraction. The rate is 50 to 70 breaths/min. Deep chest breathing is appropriate for the early phase of labor, in which the client exhibits less frequent contractions. When transition nears, a rapid pant-blow pattern of breathing is used. Slow abdominal breathing is very difficult for clients in labor. While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated and the presenting part is at 0 station. Which of the following should the nurse do first? a) Prepare the client for imminent birth. b) Note the color, amount, and odor of the amniotic fluid. c) Auscultate the client's blood pressure. d) Perform a vaginal examination to determine dilation. - Note the color, amount, and odor of the amniotic fluid. The primary health care provider orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity? - Lecithin-sphingomyelin (L/S ratio). 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: prepare for birth. complete a vaginal examination to determine dilation, effacement, and station. have naloxone hydrochloride available in the birthing room. document the client's relief due to pain medication. - Complete a vaginal examination to determine dilation, effacement, and station The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, the nurse should first: assess the client's temperature and pulse. document the color of the amniotic fluid. monitor the client's contraction pattern. assess the fetal heart rate (FHR) for 1 full minute. - assess the fetal heart rate (FHR) for 1 full minute. 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 makes which observation? a) placement of bloody sheets in a container designated for contaminated linens b) use of protective goggles during a cesarean birth c) disposal of used scalpel blades in a puncture-resistant container d) wearing of sterile gloves to bathe a neonate at 2 hours of age - wearing of sterile gloves to bathe a neonate at 2 hours of age Correct Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently? Blood pressure decreases at the peak of each contraction. Blood pressure decreases as a sign of maternal pain. Decreased blood pressure is the first sign of preeclampsia. Alterations in cardiovascular function affect the fetus. - Alterations in cardiovascular function affect the fetus. Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? - An increased sense of rectal pressure What data indicates to the nurse that placental detachment is occurring? a) An abrupt lengthening of the cord b) Decreased vaginal bleeding c) A decrease in the number of contractions d) Relaxation of the uterus - A When caring for a client with preeclampsia, which action is a priority? 1. Monitoring the client's labor carefully and preparing for a fast delivery 2. Continually assessing the fetal tracing for signs of fetal distress 3. Checking vital signs every 15 minutes to watch for increasing blood pressure 4. Reducing visual and auditory stimulation - Answer: 4 RATIONALES: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority. While performing continuous electronic monitoring of a client in labor, the nurse should document which information about the contractions? A) Duration, frequency, and intensity B) Duration, dilation,, frequency C) Frequency, duration maternal position D) Duration, effacement, position - a) Duration, frequency & intensity What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? a)beginning of one contraction to the beginning of the next contraction b) end of one contraction to the end of the next contraction c ) beginning of one contraction to the end of the next contraction d) acme of one contraction to the beginning of the next contraction - a) beginning of one contraction to the beginning of the next contraction For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes? - check the fetal HR A client hospitalized for preterm labor tells the nurse her mother in law blames her for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse?