NUR 245 PrepU - Intrapartum EXAM (GRADED A) Question and Answers | 100% CORRECT.

PrepU – Intrapartum Question 1 See full question A 39-year-old multiparous client at 39 weeks’ gestation diagnosed with class II heart disease is admitted to the hospital in active labor. What should the nurse assess first after admission to the birthing area? You Selected: • fetal position and station Correct response: • contraction frequency and intensity Explanation: When admitting a multigravid client to the birthing area, the nurse needs to obtain information about the frequency, intensity, and duration of labor contractions; the time when the labor began; whether the membranes have ruptured; and the client’s estimated childbirth date. From this information, the nurse gets a quick overview of the client’s status and can then proceed to plan effective care. Although the time when the client last had food or fluids is important, this information can be obtained later because it is less influential in determining the initial plans for care. Although information about the fetal position is important, this information is less influential in determining the initial plans for care. The client’s ability to follow directions is important, but this information can be obtained later because it plays a less influential role in initial plans for care. Question 2 See full question The primary health care provider (HCP) prescribes whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first: You Selected: • validate client information and the blood product with another nurse. Correct response: • validate client information and the blood product with another nurse. Explanation: When administering blood replacement therapy, extreme caution is needed. Before administering any blood product, the nurse should validate the client information and the blood product with another nurse to prevent administration of the wrong blood transfusion. Although baseline vital signs are necessary, she should initiate the infusion of blood slowly for the first 10 to 15 minutes. Then, if there is no evidence of a reaction, she should adjust the rate of infusion to ensure that the blood product is infused over 2 to 4 hours. The nurse can ask the client if she has ever had a reaction to a blood product, but a general question about allergies may not elicit the most complete response about any reactions to blood product administration. Blood transfusions are typically given with intravenous normal saline solution, not dextrose solutions. Question 3 See full question A client at 33 weeks' gestation is admitted in preterm labor. She is given betamethasone 12 mg IM q 24 hours × 2. What is the expected outcome of this drug therapy? You Selected: • The neonate will be born with mature lungs. Correct response: • The neonate will be born with mature lungs. Explanation: Betamethasone is a corticosteroid that induces the production of surfactant. The pulmonary maturation that results causes the fetal lungs to mature more rapidly than normal. Because the lungs are mature, the risk of respiratory distress in the neonate is lowered but not eliminated. Betamethasone also decreases the surface tension within the alveoli. Betamethasone has no influence on contractions or carrying the fetus to full term. It also does not prevent infection. Question 4 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: • Position the client on her left side Correct response: • Position the client on her left side Explanation: The supine position causes compression of the client’s aorta and inferior vena cava by the fetus. The compression, in turn, inhibits maternal circulation. The appropriate intervention would be to position the client on her left side. If that did not work, calling the healthcare provider would be the next option. Because the client is already hypotensive, having the client empty out their bladder would not be an appropriate option. Having the client hold her breath would make the hypotension worse. Question 5 See full question The nurse is caring for a client in labor. The client states she feels like she “has to push.” The vaginal exam reveals that the client is 8 cm dilated. Which of the following responses made by the nurse is correct? You Selected: • “I know you want to push, but your cervix is not dilated enough. Keep breathing through your contractions.” Correct response: • “I know you want to push, but your cervix is not dilated enough. Keep breathing through your contractions.” Explanation: Pushing (bearing down) before the cervix is completely dilated may cause edema, tissue damage, and may impede fetal descent. There is no need to call the healthcare provider, as this feeling is natural at this stage of labor. Giving the client IV pain medication at 8 cm can cause fetal respiratory distress. Question 1 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: The nurse should document the duration, frequency, and intensity of uterine contractions. Dilation refers to the number of centimeters the cervix is dilated; it doesn't describe uterine contractions. Maternal position doesn't help describe uterine contractions. Dilation and effacement both refer to the condition of the cervix, not uterine contractions. 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: • "Please do not push because you will tear your cervix." Correct response: • "I will explain what is happening to guide you as we go along." Explanation: The client is experiencing a precipitous birth. The nurse should remain calm during a precipitous birth. Explaining to the client what is happening as the birth progresses and how she can assist is likely to help her remain calm and cooperative. Maintaining eye contact is also beneficial. Telling the client that she is right and to just relax is inappropriate because the client may not be able to relax because of the strong urge to push the fetus out of the birth canal. Telling the client not to push because she may tear the cervix can instill fear, not cooperation. Saying that the health care provider (HCP) will be there soon may not be an accurate statement and is not reassuring if the client is concerned about the birth. Question 3 See full question 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: You Selected: • assess the fetal heart rate (FHR) for 1 full minute. Correct response: • assess the fetal heart rate (FHR) for 1 full minute. Explanation: After an amniotomy, the nurse should plan to first assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm or less should be promptly reported to the HCP. A cord prolapse requires prompt birth by cesarean section. The client’s contraction pattern should be monitored once labor has been established. The client’s temperature, pulse, and respirations should be assessed every 2 to 4 hours after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal pattern is present. Question 4 See full question A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? You Selected: • oxytocin 30 units in 500 ml D5W Correct response: • oxytocin 30 units in 500 ml D5W Explanation: A Bishop score evaluates cervical readiness for labor based on five factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using oxytocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft and the presenting part is at a –1 to 0 position. Prostaglandin gel, misoprostol, and dinoprostone are all cervical ripening agents, and the doses are accurate; however, cervical ripening has already taken place. Question 5 See full question Which is the priority of care for the nulliparous client who is in the active phase of the first stage of labor? You Selected: • Implementing nonpharmacologic measures for pain relief Correct response: • Implementing nonpharmacologic measures for pain relief Explanation: The active phase of labor may last up to 6 hours for the nulliparous woman. Nonpharmacologic measures for pain relief should be tried before pharmacologic measures, as this stage of labor can last for quite some time before intensifying. Respecting the client’s privacy is a self-esteem need, which prioritizes lower than pain relief. Providing information and education are important but will not prioritize higher than the client’s physiologic need for pain relief. Question 1 See full question A nurse is caring for a client who's in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate? You Selected: • Checking for the umbilical cord around the neonate's neck Correct response: • Checking for the umbilical cord around the neonate's neck Explanation: After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment is administered to the neonate after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The neonate's head isn't turned during delivery. After birth, the neonate is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after birth. Question 2 See full question 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? You Selected: • The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. Correct response: • The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. Explanation: Regular contractions 3 minutes apart and 1 minute in duration along with an urge to push, as exhibited in the second client, indicate a pending delivery. Priority should be assigned to this client. Leaking amniotic fluid that appears to be clear, as exhibited in the first client, doesn't indicate that contractions are about to begin. This client is less of a priority. Question 3 See full question A client who is positive for human immunodeficiency virus (HIV) tells the nurse that her significant other is the only family member who knows her health status. What should the nurse do to keep the client's health status confidential? Select all that apply. You Selected: • Ask all family members, except the client's significant other, to wait outside when she's educating the client. • Use the hospital code for HIV when documenting care. Correct response: • Use the hospital code for HIV when documenting care. • Ask all family members, except the client's significant other, to wait outside when she's educating the client. Explanation: Every facility uses a specific code to designate HIV-positive clients. To protect confidentiality, the nurse should speak about the diagnosis only with the client and any person the client designates. A nurse should never discuss a client with anyone who is not directly involved in that client's care. For instance, if the client does not give the nurse permission to speak with the client's mother, the nurse may not give the mother information about the client. Keeping a log of all HIV-positive clients violates client confidentiality. Question 4 See full question A client isn't progressing with dilation during labor. Her physician recommends a cesarean birth to minimize the potential for fetal distress. After surgery, what should the nurse assess for in this client? Select all that apply. You Selected: • Hemorrhage Correct response: • Infection • Hemorrhage • Hematuria Explanation: A client who's had a cesarean birth is at increased risk for infection, hemorrhage, and hematuria resulting from the surgical process. There's no evidence to suggest this client is at a higher risk for mastitis or endometritis. Question 5 See full question The nurse who is assessing the position, presentation, and lie of the fetus of a 9-month-pregnant woman performs which of the following actions? You Selected: • Leopold's maneuvers Correct response: • Leopold's maneuvers Explanation: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis. The nurse assesses for these through Leopold’s maneuvers, a series of four palpations of the uterus and fetus through the abdominal wall. Cardinal movements are the seven movements that occur as the fetus moves through the birth canal. A digital vaginal exam helps to determine dilation and effacement. The Friedman curve is a graphical representation of cervical dilation and fetal station. Question 1 See full question The third stage of labor ends: You Selected: • after the delivery of the placenta. Correct response: • after the delivery of the placenta. Explanation: The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth. Question 2 See full question A nurse is evaluating an external fetal monitoring strip. Identify the area on this strip that causes her to be concerned about uteroplacental insufficiency. You Selected: • Your selection and the correct area, market by the green box. Explanation: This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate begins at the end of the contraction and doesn't return to baseline until the contraction is over. Late decelerations are associated with uteroplacental insufficiency, shock, or fetal metabolic acidosis. Question 3 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: • have naloxone hydrochloride available in the birthing room. Correct response: • complete a vaginal examination to determine dilation, effacement, and station. Explanation: The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client’s signs and symptoms by checking to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining naloxone. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client. Question 4 See full question A primigravida client arrives at the labor and childbirth unit at 39 weeks gestation. Once completing the initial assessment, the nurse documents the note above. Which nursing action is initiated? You Selected: • Instructing the client to rest and turn on the left side. Correct response: • Providing discharge home with instruction to ambulate. Explanation: The nurse identifies the client as being in early labor by symptoms of back pain, varying contractions, moderate pain, and cervical dilation of 4 cm. The nurse identifies the normal progress of labor thus far and conveys to the health care provider. Until the health care provider admits the client, it is appropriate to have the client discharged with instruction to ambulate. Typically the client is instructed to return to the birthing center/hospital when contractions are 4-5 minutes apart. Ambulation may progress the labor process. The client does not need to turn on her left side as there is no sign of fetal compromise. The client is considered a full term pregnancy. There is no indication of a need for a cesarean section. Question 5 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: • wearing of sterile gloves to bathe a neonate at 2 hours of age Correct response: • wearing of sterile gloves to bathe a neonate at 2 hours of age 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. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers. Question 1 See full question A primigravid with severe gestational hypertension has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next? You Selected: • Increase the infusion rate by 5 gtt/minute. Correct response: • Stop the magnesium sulfate infusion. Explanation: Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls or if reflexes are diminished or absent. The client may also show other signs of impending toxicity, such as flushing and feeling warm. Continuing to monitor the client won't resolve the client's suppressed DTRs and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down. Question 2 See full question The primigravid client is at +1 station and 9 cm dilated. Based on these data, the nurse should first: You Selected: • encourage the client to breathe through the urge to push. Correct response: • encourage the client to breathe through the urge to push. Explanation: The urge to push is often present when the fetus reaches + stations. This client does not have a cervix that is completely dilated and pushing in this situation may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate strategy and allows the cervix to dilate before pushing. Increasing the level of the epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated. Comfort measures are important for the client at this time but are not the highest priority for the nurse. Question 3 See full question After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? You Selected: • flex her thighs onto her abdomen before bearing down Correct response: • hold her breath throughout the length of the contraction Explanation: The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing. Semi-Fowler’s position enhances the effectiveness of the abdominal muscle efforts during pushing, but the client can assume a squatting or side-lying position if desired. The client should flex her thighs onto her abdomen before bearing down to decrease the length of the vagina and increase the pelvic diameter. The client should exert downward pressure as if she were having a bowel movement while pushing. Question 4 See full question The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what should the nurse do first? You Selected: • Prepare a clean area on which to receive the neonate. Correct response: • Prepare a clean area on which to receive the neonate. Explanation: Because the birth is imminent and no additional help is available, the nurse should immediately prepare a clean area for childbirth. Most agency labor units have emergency birth packs with sterile towels, a bulb syringe, and a cord clamp. Having the client push with a contraction may push the head out quickly, resulting in tearing of the perineum. The nurse should instruct the client to pant or pant/blow to decrease the urge to push. Trying to delay the birth is contraindicated. The head of the bed should be elevated to about 45 degrees, not lowered. The client should assume a position of comfort. Question 5 See full question A primigravida client in labor is now fully dilated and effaced after 8 hours in labor. The client asks the nurse, "When is this going to be over? It hurts so bad!" What is the best response by the nurse? You Selected: • "You are progressing well and the second stage of labor should be complete within an hour." Correct response: • "You are progressing well and the second stage of labor should be complete within an hour." Explanation: The average length of time for the second stage of labor for a primigravada is 1 hour. Longer than 1 hour might mean the client is experiencing an arrest in descent. Encouraging the client that she is progressing will assist her to focus on breathing and pushing. Indicating that there may be something wrong with the baby can create anxiety. Fifteen minutes for completion of the second stage of labor for a primigravada is not generally realistic. Informing the client that the nurse “can’t really tell her” is not educating the client. Question 1 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: When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with administration of epidural anesthesia. Question 2 See full question After the vaginal birth of a term neonate, the nurse determines that the placenta is about to separate when which occurs? You Selected: • A sudden gush of dark blood occurs. Correct response: • A sudden gush of dark blood occurs. Explanation: A sudden gush of dark blood, a lengthening of the umbilical cord, a smaller uterus, and changing of the uterus to a round or spherical shape are impending signs of placental separation. Pushing effort from the client is not a reliable indicator for impending placental separation, nor is it necessary for placental expulsion. Question 3 See full question While waiting for the placenta to deliver, the nurse should not take any action before: You Selected: • observing for signs of placental separation. Correct response: • observing for signs of placental separation. Explanation: The best course of action is to wait for signs of placental separation, such as lengthening of the umbilical cord, a slight gush of dark blood, and a change in the contour of the fundus from discoid to globular. Pulling on the cord before the placenta is delivered may cause inversion of the uterus. After separation occurs, the client can be asked to bear down. Massaging the fundus is not helpful to ensure placental separation. Reaching into the uterus is done only when the placenta does not separate, necessitating manual removal. Doing so can lead to infection or uterine trauma. Question 4 See full question A nurse is teaching a primipara and her partner about the labor and birth process. The nurse describes the maneuvers that the fetus goes through during the labor process when the head is the presenting part. Place the maneuvers below in the order in which the nurse should explain that they occur. All options must be used. You Selected: • engagement • descent • flexion • internal rotation Correct response: • engagement • descent • flexion • internal rotation Explanation: Engagement describes when the fetus enters the true pelvis; it occurs before descent in primiparas and concurrently in multiparous women. If the head is the presenting part, after engagement occurs, the normal order of maneuvers (cardinal movements) during labor and birth is descent, flexion, internal rotation, extension, external rotation, and expulsion. They occur as the fetal head passes through the maternal pelvis during the normal labor process. Question 5 See full question A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which of the following rates would cause the nurse to intervene? You Selected: • 161–200 beats per minute Correct response: • 60–79 beats per minute Explanation: This fetal heart rate (FHR) could indicated fetal distress and should be evaluated first. In a full-term fetus, the baseline FHR normally ranges from 121–160 beats per minute. The greatest concern would be the lowest fetal heart rate range. Question 1 See full question Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? You Selected: • "What is your expected due date?" Correct response: • "What is your expected due date?" Explanation: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons. Question 2 See full question During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? You Selected: • Maternal hypotension Correct response: • Maternal hypotension Explanation: As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, and fetal and maternal bradycardia (not tachycardia). Although the client may experience some postpartum urine retention, maternal oliguria isn't associated with epidural anesthesia. Question 3 See full question Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first: You Selected: • assess the client's cervical dilation and station. Correct response: • assess the client's cervical dilation and station. Explanation: The nurse should assess the client’s cervical dilation and station because the client’s symptoms are indicative of the transition phase of labor. Multiparous clients can proceed 5 to 9 cm/h during the active phase of labor. Warming the temperature of the room is not helpful because the client will soon be ready to begin expulsive pushing. Increasing the intravenous fluid rate is not warranted unless the client is experiencing dehydration. Administration of an antiemetic at this point in labor is not warranted and may result in neonatal depression should a rapid birth occur. Question 4 See full question Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? You Selected: • Place the client in a Trendelenburg position. Correct response: • Place the client in a Trendelenburg position. Explanation: The first step in managing a cord prolapse is to relieve pressure on the cord. Immediate measures include lowering the client’s head by using the Trendelenburg position or knee-to-chest position so that the fetal presenting part will move away from the pelvis and moving the fetal presenting part off the cord by applying pressure through the vagina with a sterile gloved hand. An immediate cesarean birth is usually performed. Oxytocin would not be given because the drug stimulates uterine contractions, putting further pressure on the cord as the contractions attempt to expel the fetus. Pushing results in further cord compression and decreased fetal heart rate. With cord prolapse, an immediate cesarean birth is indicated. There is no need to cover the cord to avoid damage or tearing. Question 5 See full question The primary care provider orders magnesium sulfate intravenously for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when: You Selected: • contractions cease. Correct response: • contractions cease. Explanation: Tocolytics are used to stop uterine contractions. Sedation is not its purpose of a tocolytics. Tocolyitics have no effect on placental perfusion or the fetal pulmonary system or lung function. Question 1 See full question A primigravid with severe gestational hypertension has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next? You Selected: • Increase the infusion rate by 5 gtt/minute. Correct response: • Stop the magnesium sulfate infusion. Explanation: Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls or if reflexes are diminished or absent. The client may also show other signs of impending toxicity, such as flushing and feeling warm. Continuing to monitor the client won't resolve the client's suppressed DTRs and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed down. Question 2 See full question A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred? You Selected: • Complete uterine rupture Correct response: • Complete uterine rupture Explanation: In complete uterine rupture, the client feels a sharp pain in the lower abdomen and contractions stop. Fetal heart rate also stops within a few minutes. In abruptio placentae, uterine instability would continue to be indicated by the fetal heart monitor tracing. With cord prolapse, contractions would continue and the client wouldn't experience pain from the prolapse itself. Although vaginal bleeding occurs with partial placenta previa, the client has no pain outside of the expected pain of contractions. Question 3 See full question A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? You Selected: • Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. Correct response: • Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Explanation: The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Explaining what the fetal scalp electrode is, how it's applied, and that bedrest is required after application provides correct information about fetal scalp electrode application; however, these statements don't address the client's clinical situation, which prevents fetal scalp electrode application. The fetal scalp electrode helps monitor fetal heart rate, but it doesn't shorten labor. Question 4 See full question The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use? You Selected: • prolonged pressure on specific sites Correct response: • light stroking of the skin surface Explanation: Light stroking of the skin, or effleurage, is commonly used with the Lamaze method of childbirth preparation. Light abdominal massage with just enough pressure to avoid tickling is thought to displace the pain sensation during a contraction. Deep kneading and secure grasping are typically associated with relaxation massages to relieve stress. Prolonged pressure on specific sites is associated with acupressure. Question 5 See full question A client in labor received an epidural for pain management. Before receiving the epidural, the client’s blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client’s blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), the nurse should: You Selected: • perform a vaginal examination. Correct response: • turn the client to her side. Explanation: The nurse should turn the client to the side to reduce pressure on the abdominal aorta. The IV fluid rate would be increased, not decreased. There is no information indicating the client has a full bladder or requires a vaginal examination. Question 1 See full question A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding alerts the nurse to an increased risk for fetal distress? You Selected: • Blood pressure of 146/90 mm Hg Correct response: • Blood pressure of 146/90 mm Hg Explanation: A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus. Question 2 See full question A client states that her "water broke." Which action requires the nurse to have specialialized training? You Selected: • Conducting a bedside ultrasound for an amniotic fluid index Correct response: • Conducting a bedside ultrasound for an amniotic fluid index Explanation: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with Nitrazine paper, and observing for flakes of vernix are appropriate nursing assessments for determining whether a client has ruptured membranes. Question 3 See full question Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? You Selected: • excitement Correct response: • loss of control Explanation: Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts. Question 4 See full question During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem? You Selected: • respiratory distress syndrome Correct response: • respiratory distress syndrome Explanation: Respiratory distress syndrome is more common in neonates born by cesarean section than in those born vaginally. During a vaginal birth, pressure is exerted on the fetal chest, which aids in the fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with a cesarean birth. Congenital anomalies are not more common with cesarean birth. Pulmonary hypertension occurs more commonly in infants with meconium aspiration syndrome, congenital diaphragmatic hernia, respiratory distress syndrome, or neonatal sepsis, not with cesarean birth. Meconium aspiration syndrome occurs more commonly with vaginal birth, postterm neonate, and prolonged labor, not with cesarean birth. Question 5 See full question The nurse is assisting with birth to a multigravida in active labor who is not having anesthesia. The, client's cervix is completely dilated. The nurse should assist the the client to deliver the fetal head by pushing: You Selected: • as soon as a contraction begins. Correct response: • when she has an urge to push. Explanation: The best approach is to allow the client to push when she feels the urge to push with a contraction. When the contraction begins, the client may have an immediate urge to push, or it may take time for fetal descent to stimulate stretch receptors. Urging the client to push before she feels the urge may needlessly tire her. Pushing at the end of a contraction or between contractions is not as effective as pushing when the client feels the urge. Additionally, clients should rest between contractions. Question 1 See full question The third stage of labor ends: You Selected: • after the delivery of the placenta. Correct response: • after the delivery of the placenta. Explanation: The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth. Question 2 See full question A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding? You Selected: • Early decelerations Correct response: • Early decelerations Explanation: A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they are called early decelerations. Early decelerations result from head compression during normal labor and do not indicate fetal distress. Prolonged decelerations, also known as reflex bradycardia, are decreases in the FHR that last 60 to 90 seconds. These decelerations occur in response to sudden vagal stimulation. Prolonged decelerations may indicate fetal distress. Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends. Accelerations are transient rises in the FHR that are normally caused by fetal movements and uterine contractions. Question 3 See full question A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next? You Selected: • Reposition the client and continue to evaluate the tracing. Correct response: • Reposition the client and continue to evaluate the tracing. Explanation: The cause of variable decelerations is cord compression, which may be relieved by moving the client to one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing a vaginal examination will let the nurse know how far dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by position changes, oxygen should be initiated, but the rate should be 8 to 10 L/min. Notifying the HCP should occur if turning the client and administering oxygen does not relieve the decelerations. Question 4 See full question The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She's too upset by what is happening to make this decision." The nurse should: You Selected: • ask the client to sign the consent form. Correct response: • ask the client to sign the consent form. Explanation: Preparation for cesarean birth is similar to preparation for any abdominal surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain designated people can do so legally. The husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery may be performed without a written consent if it is done to save the life of the mother or the child, or both. Question 5 See full question The nurse is caring for a client in labor who is receiving epidural anesthesia. The nurse assesses a blood pressure of 80/40 mm Hg. Which of the following interventions will the nurse include in the client’s plan of care? You Selected: • Monitor the fetal heart rate Correct response: • Increase the client’s fluid rate Explanation: A hypotensive crisis may occur after administering epidural anesthesia. The immediate intervention for this type of crisis is to increase the fluid rate. Question 1 See full question A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion? You Selected: • Fetal heart rate variability within 5 to 10 beats/minute Correct response: • Fetal heart rate variability within 5 to 10 beats/minute Explanation: Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 5 to 10 beats per minute is considered normal. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the intervillous spaces during uterine contractions — an abnormal pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe fetal anemia or asphyxiation. Question 2 See full question A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor? You Selected: • cervical dilation and effacement Correct response: • cervical dilation and effacement Explanation: True labor is present when cervical dilation and effacement occur. Fetal descent into the pelvic inlet is an indication that labor will begin soon. However, for a nulligravid client, this may take 1 to 2 weeks. Painful contractions every 3 to 5 minutes may be Braxton Hicks contractions. Contractions that disappear when the client lies down are a sign of false labor. Although leaking amniotic fluid should be reported, it is not a sign of true labor. Question 3 See full question Assessment of a primigravida in active labor reveals cervical dilation at 9 cm with complete effacement and the fetus at +1 station. What should the nurse do when the primary care provider prescribes meperidine 50 mg intramuscular (IM) for the client? You Selected: • Be certain that naloxone is at the client's bedside. Correct response: • Refuse to administer the medication to the client. Explanation: The nurse should refuse to administer the medication to the client because of the risk of respiratory depression in the neonate. Meperidine, given IM, peaks in 30 to 60 minutes and lasts 2 to 4 hours. Based on the assessment findings, the client most likely will be giving birth within that time frame, increasing the risk for respiratory depression in the neonate, a serious consequence. Therefore, the nurse should not administer the drug. Naloxone should be readily available whenever narcotics that can result in respiratory depression are used. Asking the primary care provider to validate the dosage is not necessary. For clients in early labor, meperidine can be given IM in dosages ranging from 50 to 100 mg. Question 4 See full question A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important? You Selected: • maternal pulse Correct response: • fetal heart rate Explanation: The anesthetic used for the epidural block may cause relaxation of maternal blood vessels, leading to lower maternal blood pressure. The decrease in maternal blood pressure causes oxygenated blood to move more slowly to the fetus, commonly leading to a lower fetal heart rate and hypoxia. A major complication is a decreased fetal heart rate. Thus, assessment of fetal heart rate is most important. While measuring maternal pulse is important, this vital sign does not tell the nurse as much about fetal perfusion as the fetal heart rate or maternal blood pressure. Epidural anesthesia has no effect on the status of the membranes or the color of the amniotic fluid. The membranes may rupture spontaneously or by amniotomy. The person responsible for administering the anesthesia would be responsible for determining the level of anesthesia. Although some clients may sleep after an epidural, the client normally remains conscious while under the influence of regional anesthesia, such as an epidural block. Assessing the level of consciousness, although important for any client, is not the priority following epidural anesthesia. Question 5 See full question During labor, a low-risk multigravid client in active labor has begun pushing, and the fetal head is beginning to crown. To prevent perineal lacerations during the birth, the nurse should: You Selected: • stretch the perineal tissues with sterile gloved fingers. Correct response: • stretch the perineal tissues with sterile gloved fingers. Explanation: Sterile gloves should always be worn by birth attendants to prevent infection to the laboring client and the fetus. Stretching the perineal muscles can decrease the incidence of tearing or lacerations. Holding the fetal head back, even with a sterile gloved hand, is inappropriate because it can cause injury to the fetus. The fetus is ready to be born. Telling the client not to push for two contractions is inappropriate because the fetus is ready to be born. Asking her to hold her breath is inappropriate because doing so while pushing may result in a Valsalva maneuver, leading to possible fetal compromise and maternal increased intracranial pressure. Show Less