Nurs 304 Exam 2

A nurse is caring for who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula at 2 L/min B. Apply a warm blanket C. Assist the client to a side-lying position D. Place an oxygen mask over the clients nose and mouth - D. Place an oxygen mask over the clients nose and mouth A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? A. Abdominal effleurage B. Sacral Counterpressure C. Showering if not contraindicated D. back rub and massage - B. Sacral Counterpressure A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that the cervix is 3 cm dilated, 80% effaced , and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? ( Select all that apply.) A. Encourage use of patterned breathing techniques B. Insert an indwelling urinary catheter C. Administer opioid analgesic medication D. Suggest application of cold E. Provide ice chips - A. Encourage use of patterned breathing techniques C. Administer opioid analgesic medication D. Suggest application of cold A nurse is caring for a client who is in the second stage of labor. The clients labor has been progressing , and a vaginal birth is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? A. Pudendal B. Epidural C. Spinal D. Paracervical - A. Pudendal NUR 304 NUR 304 A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make? A. " It is needed to promote increased urine output." B. " It is needed to counteract respiratory depression." C. " It is needed to counteract hypotension." D. " It is needed to prevent oligohydramnios." - C. " It is needed to counteract hypotension." A nurse is performing leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb and fingers D. Stand facing client's feet with fingertips outlining cephalic prominence. - B. Palpate the fundus of the uterus A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions - D. Relaxation between uterine contractions A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse would take? A. Assist the client into the left-lateral position B. Apply a fetal scalp electrode C. Insert an IV catheter D. Perform a vaginal exam - A. Assist the client into the left-lateral position A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? ( Select all that apply.) A. It is considered a noninvasive procedure B. It can detect abnormal fetal heart tones early C. IT can determine the amount of amniotic fluid you have D. It allows for accurate readings with maternal movement E. It can measure uterine contraction intensity - B. It can detect abnormal fetal heart tones early D. It allows for accurate readings with maternal movement E. It can measure uterine contraction intensity A nurse is caring for a client who is at 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? NUR 304 NUR 304 A. Examine the amniotic fluid for meconium B. Check the FHR C. Dry the client and make them comfortable D. Apply a tocotransducer - B. Check the FHR A nurse is completing an admission assessment for a client who is at 39 weeks gestation and reports fluid leaking from the vagina for two days. Which of the following conditions is the client at risk for? A. Cord prolapse B. Infection C. Postpartum Hemorrhage D. Hydramnios - B. Infection A client calls a providers office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did not notice blood when wiping after voiding. Which of the following manifestations is the client experiencing ? A. Braxton hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions - D. True contractions A nurse is planning care for a newly admitted client who reports " I am in labor, and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? A. Inspect the inroitus for a prolapsed cord B. Perform a test to identify the ferning pattern C. Monitor station of the presenting part D. Defer vaginal examinations - D. Defer vaginal examinations A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make? A. A full bladder increase the risk for fetal trauma B. A full bladder increases the risk for bladder infections C. A distended bladder will be traumatized by frequent pelvic exams D. A distended bladder reduces pelvic space needed for birth - D. A distended bladder reduces pelvic space needed for birth A nurse is caring for a client and partner during the second stage of labor. The clients partner asks the nurse to explain how to know when crowning occurs. Which of the following responses should the nurse make? A. The placenta will protrude from the vagina B. Your partner will report a decrease in the intensity of contractions C. The vaginal area will bulge as the babys head appears D. Your partner will report less presure - C. The vaginal area will bulge as the babys head appears NUR 304 NUR 304 Which of the following findings indicates placental separation? (select all that apply.) A. Lengthening of umbilical cord B. Swift gush of clear amniotic fluid C. Softening of the lower uterine segment D. Appearance of dark blood from the vagina E. Fundus firm upon palpation - A. Lengthening of umbilical cord D. Appearance of dark blood from the vagina E. Fundus firm upon palpation A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to begin an amnioinfusion. Which of the following conditions should the nurse plan to prepare an amnioinfusion? (Select all that apply.) A. Oligohydramnios B. Hydramnios C. Fetal cord compression D. Hydration E. Fetal immaturity - A. Oligohydramnios C. Fetal cord compression A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? A. Fetal engagement B. Fetal lie C. Fetal attitude D. Fetal position - A. Fetal engagement A nurse is caring for client who had no prenatal care, is Rh- negative, and will undergo an external version at 37 weeks of gestation. Which of the following medication should the nurse plan to administer prior to the version?A. Prostaglandin gel B. Magnesium sulfate C. Rho(D) immune globulin D. Oxytocin - C. Rho(D) immune globulin A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? A. Frequency of every 2 min B. Duration of 90 to 120 seconds C. Intensity of 60 to 90 mm Hg D. Resting tone of 15 mm Hg - B. Duration of 90 to 120 seconds NUR 304 NUR 304 A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. Precipitous labor B. Premature rupture of membranes C. Post maturity syndrome D. Prolapsed umbilical cord - D. Prolapsed umbilical cord A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? a. IUGR b. Hyperglycemiac. C. Meconium aspiration d. Polydramnios - C. Meconium aspiration A nurse is caring for a client in active labor. When last examined 2 hours ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states " My water broke." The monitor reveals a FHR of 80-85/min, and the nurse performs a vaginal examination, noticing clear liquid and pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first?a. Place the client in the Trendelenberg position b. Apply pressure to the presenting part with her fingers c. Administer O2 at 10L/min via a face mask d. Initiate IV fluids - b. Apply pressure to the presenting part with her fingers A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? a. Hands and knees b. Lithotomy c. Trendenlenberg d. Supine with a rolled towel under one hip - a. Hands and knees A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increase the risk for which of the following complications? a. Prolonged labor b. Reduced fetal O2 supply c. Delayed cervical dilation d. Increased maternal stress - b. Reduced fetal O2 supply