RNSG 2363 Reproduction – Labor Quiz 2020 _ San Antonio College | RNSG2363 Reproduction – Labor Quiz 2020 _ Grade A

RNSG 2363 Reproduction – Labor Quiz 2020 _ San Antonio College Mobility level II Clinicals Reproduction – Labor Quiz 1. A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 secs., and are strong to palpitations. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and return to baseline after contraction is over. Which of the following actions should the nurse take? a. Decrease the rate of infusion of the maintenance IV solution b. Discontinue the infusion of the IV oxytocin Discontinue the oxytocin infusion immediately if the client is experiencing late decelerations due to uterine hyperstimulation. c. Increase the rate of infusion of the IV oxytocin d. Slow the client’s rate of breathing 2. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?a. Encourage the client to perform Kegel exercises b. Encourage the client to move to the left lateral position c. Ask the client to rate her pain d. Assist the client to the bathroom to void A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage. 3. A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? a. Cover the cord with a sterile, moist saline dressing b. Prepare the client for an immediate birth c. Place the client in knee-chest position d. Insert a gloved hand into the vagina to relieve pressure on the cord This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation to the fetus. 4. A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15/min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make?a. A negative test b. A nonreactive test An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15/min above the FHR baseline and last at least 15 seconds. c. A positive test d. A reactive test 5. A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9lb 6oz. (4252g). The nurse should recognize that this client is at risk for which of the following postpartum conditions? a. Puerperal infection b. Retained placental fragments c. Thrombophlebitis d. Uterine atony A uterus that is over distended, such from a macrosomic fetus, has an increased risk for uterine atony. 6. A nurse is caring for a client who is 40 weeks gestation and is in active labor. The client has 6cm of cervical dilation and 100% effacement. The nurse obtains the client’s blood pressure reading as 82/52mm Hg. Which of the following interventions should the nurse perform? a. Prepare for a cesarean birth b. Assist the client to an upright position c. Prepare for an immediate vaginal deliveryd. Assist the client to turn onto her side Maternal hypotension results from the pressure of the enlarged uterus of the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range. 7. A nurse is caring for a client who is primigravida, at term, and having contractions but is stating that she is “not really sure if she is in labor or not”. Which of the following should the nurse recognize as a sign of true labor? a. Rupture of the membranes b. Changes in the cervix Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of labor. c. Station of the presenting part d. Pattern of contractions 8. A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client’s skin color is ashen, and she states she feels weak and lightheaded. After applying oxygen via nonrebreather mask at 10L/min which of the following actions should the nurse take next? a. Insert an indwelling urinary catheter b. Administer oxytocin by continuous IV infusion c. Tilt the client onto her right side with her legs elevated to at least 30 degrees d. Massage the client’s fundus to promote contractionsA soaked perineal pad in less than 15 min, ashen skin color, and report of weakness and light-headedness can indicate that the client is at greater risk for hypovolemic shock. Therefore, the next action the nurse should take is to massage the client’s fundus to expel blood clots and promote uterine contraction to stop the bleeding. 9. A nurse is planning care for a client who is 2 hr postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? a. Apply warm, moist heat to the client’s lower extremities b. Massage the client’s posterior lower legs c. Place pillows under the client’s knees when resting in bed d. Have the client ambulate Venous stasis is a major cause of thrombophlebitis. To prevent clot formation, have the client ambulate as soon as she can after delivery and as often as possible. 10. A nurse is caring for a client who experienced a vaginal delivery 12 hrs ago. When palpating the abdomen, at which of the following positions should the nurse expect to find the uterine fundus? a. At the level of the umbilicus Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day. b. 2 cm above the umbilicusc. One fingerbreadth above the symphysis pubis d. To the right of the umbilicus 11. A nurse is admitting a client who is at 33 weeks gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? a. Monitor vaginal bleeding b. Administer glucocorticoids c. Insert an IV catheter d. Apply an external fetal monitor Based on Maslow’s hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress 12.A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client’s blood pressure is 80/40mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? a. Elevate the client’s legs b. Monitor vital signs every 5 mins c. Notify the provider d. Place the client in a lateral position Based on Maslow’s hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client’s hips to relieve pressure on the inferior vena cava and improve the blood pressure13.A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? a. Variable decelerations are due to umbilical cord compression Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus b. Variable decelerations are caused by uteroplacental insufficiency c. Variable decelerations are a result of the administration of IV narcotic analgesic d. Variable decelerations are related to fetal head compression 14.A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? a. Document the findings and continue to monitor the client These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document her findings and continue to monitor the client.b. Notify the client’s provider c. Increase the frequency of fundal massage d. Encourage the client to empty her bladder 15.A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining the client’s history, the client tells the nurse that she takes the herb feverfew for migraine headaches. Which of the following actions should the nurse take? a. Tell the client that she should take an over-the-counter analgesic instead b. Explain to the client that she should not take this herb while she is pregnant The nurse should explain that feverfew interferes with platelet action and can therefore cause bleeding. It is unsafe for the client to take during pregnancy. c. Ask the client why she would take an herb during pregnancy d. Suggest that the client ask her herbalist within the next few weeks about taking it while pregnant 16.A nurse is providing education to a client who is in labor and has a prescription for a continuous IV infusion of oxytocin. Which of the information should the nurse include? a. “This medication will help prevent nausea and vomiting.” b. “Your contractions will become stronger and more frequent.” Oxytocin in diluted with sodium chloride and administered IV via an infusion pump device to induce or strengthen uterine contractions during labor. The client who is receiving an oxytocindrip is closely monitored to promote a safe delivery and prevent maternal and/or fetal complications. The desired concentration of oxytocin medication is determined by the desired labor contraction pattern that should increase in frequency, duration and intensity. The nurse closely monitors risks of continuous IV infusion of oxytocin to determine when to discontinue the medication. Risks include fetal distress (fetal bradycardia) caused by hyperstimulation of the uterus compromising blood flow to the fetus. Uterine contractions lasting longer than 90 seconds should prompt the nurse to discontinue medication. c. “I will remove the electric fetal monitor once contractions are regular.” d. “You can push the button on the control device to administer more medication.” 17.A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? a. Examination to determine cervical status b. A magnesium sulfate infusion c. Initiation of pushing d. Preparation of cesarean birth A cesarean birth is indicated for all clients who have a confirmed placenta previa.18.A nurse is caring for a client who is 12hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? a. Orthostatic hypotension b. Fundus palpable at the umbilicus c. Urine output of 3000mL in 12hr d. Heart rate of 110/min A rapid or increasing heartrate can be a manifestation of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for evidence of postpartum hemorrhage. 19.A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? a. The presenting part is 1cm above the ischial spines Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below or at the level of the spines. If the station is (-)1, then the presenting part is 1cm above the ischial spines. b. The presenting part is 1cm below the ischial spines c. The cervix is 1cm dilated d. The cervix is effaced 1cm 20. A nurse is a provider’s office is caring for a client who is at 34 weeks gestation and at risk for placental abruption. The nurse shouldrecognize that which of the following is the most common risk factor for abruption? a. Cocaine use b. Hypertension Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption c. Blunt force trauma d. Cigarette smoking