Intrapartum NCLEX questions & Answers 2022| Complete Solution With Rationale

Intrapartum NCLEX questions & Answers 2022| Complete Solution With Rationale 1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A.The client begins to expel clear vaginal fluid B.The contractions are regular C.The membranes have ruptured D.The cervix is dilated completely 1.4. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate. A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion 3. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? 1.Fetal heart rate of 180 beats per minute 2.White blood cell count of 12,000 3.Maternal pulse rate of 85 beats per minute 4.Hemoglobin of 11.0 g/dL 1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy. A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: 1.Trendelenburg's position with the legs in stirrups 2.Semi-Fowler position with a pillow under the knees 3.Prone position with the legs separated and elevated 4.Supine position with a wedge under the right hip 4. Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. . A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: 1.Noting if the heart rate is greater than 140 BPM 2.Placing the diaphragm of the Doppler on the mother abdomen 3.Performing Leopold's maneuvers first to determine the location of the fetal heart 4.Palpating the maternal radial pulse while listening to the fetal heart rate 4. The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates. 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? 1.Three contractions occurring within a 10-minute period 2.A fetal heart rate of 90 beats per minute 3.Adequate resting tone of the uterus palpated between contractions 4.Increased urinary output 2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period. 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? 1.Placing the client on complete bed rest 2.Continuous electronic fetal monitoring 3.An IV infusion of antibiotics 4.Placing a code cart at the client's bedside 2. Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin. 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? 1.Encourage the client's coach to continue to encourage breathing exercises 2.Encourage the client to continue pushing with each contraction 3.Continue monitoring the fetal heart rate 4.Notify the physician or nurse mid-wife 4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified. 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? 1.Document the findings and tell the mother that the monitor indicates fetal well-being 2.Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. 3.Notify the physician or nurse mid-wife of the findings. 4.Reposition the mother and check the monitor for changes in the fetal tracing 1. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? 1.Identifying the types of accelerations 2.Assessing the baseline fetal heart rate 3.Determining the frequency of the contractions 4.Determining the intensity of the contractions 2. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at -1 station. The nurse determines that the fetal presenting part is: 1.1 cm above the ischial spine 2.1 fingerbreadth below the symphysis pubis 3.1 inch below the coccyx 4.1 inch below the iliac crest 1. Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines. A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? 1.A loud mouth 2.Low self-esteem 3.Hemorrhage 4.Postpartum infections 4. Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Having a loud mouth is only related to the person typing up this test. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: 1.Hematoma 2.Placenta previa 3.Uterine atony 4.Placental separation 4. As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased maternal blood pressure monitoring 2. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? 1.Early decelerations 2.Variable decelerations 3.Late decelerations 4.Short-term variability 2. Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: 1.A form of biofeedback to enhance bearing down efforts during delivery 2.Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus 3.The application of pressure to the sacrum to relieve a backache 4.Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest 2. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus. A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: 1.Exhaustion 2.Fear of losing control 3.Involuntary grunting 4.Valsalva's maneuver 2. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor. A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. 1.Stop of Pitocin infusion 2.Perform a vaginal examination 3.Reposition the client 4.Check the client's blood pressure and heart rate 5.Administer oxygen by face mask at 8 to 10 L/min 1, 4, 2. 5, 3. If uterine hypertonicity occurs, the nurse immediately would intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? 1.Medication that will provide sedation 2.Increased hydration 3.Oxytocin (Pitocin) infusion 4.Administration of a tocolytic medication 3. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: 1.Monitor the Pitocin infusion closely 2.Provide pain relief measures 3.Prepare the client for an amniotomy 4.Promote ambulation every 30 minutes 2. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? 1.Keeping the significant other informed of the progress of the labor 2.Providing comfort measures 3.Monitoring fetal heart rate 4.Changing the client's position frequently 3. The priority is to monitor the fetal heart rate. A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: 1.Over the fetus that is most anterior to the mothers abdomen 2.Over the fetus that is most posterior to the mothers abdomen 3.So that each fetal heart rate is monitored separately 4.So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus 3. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? 1.Disseminated intravascular coagulation 2.Chronic hypertension 3.Infection 4.Hemorrhage 4. Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.