Intrapartum Exam Study Guide Questions And Answers Verified 100% Correct

Intrapartum Exam Study Guide Questions And Answers Verified 100% Correct The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? - ANSWER 2. Monitoring the fetal heart rate The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. - ANSWER 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? - ANSWER 1. The client's fear The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. - ANSWER 1. Petechiae 2. Hematuria 4. Prolonged clotting times 5. Oozing from injection sites The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? ANSWER 1. Forceps delivery - The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? - ANSWER 2. Breathe rapidly. The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? - ANSWER 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? - ANSWER 2. Every 15 minutes The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? - ANSWER 3. Palpating the maternal radial pulse while listening to the FHR The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? - ANSWER 2. A fetal heart rate of 90 beats/minute The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? - ANSWER 3. Continuous electronic fetal monitoring The 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 which condition? - ANSWER 4. Placental separation During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? - ANSWER 2. Prevent dehydration and hypoxemia. A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? - ANSWER 1. Measure fundal height. The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? - ANSWER 2. Clear and maintain an open airway. A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? - ANSWER 4. Painless vaginal bleeding A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. - ANSWER 3. Increase in fundal height 4. Hard, boardlike abdomen 5. Persistent abdominal pain The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? - ANSWER 1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? - ANSWER 4. Pale straw in color, with flecks of vernix A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? - ANSWER 2. Continue to monitor the client. The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. - ANSWER 1. Keep the room semi-dark. 2. Initiate seizure precautions. 3.