Maternal-Child (Intrapartum) - Test Bank With Rationale

Maternal & Child (Intrapartum) 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 2. 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: A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of pitocin IV infusion 3. 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? A. Fetal heart rate of 180 beats per minute B. White blood cell count of 12,000 C. Maternal pulse rate of 85 beats per minute D. Hemoglobin of 11.0 g/dL 4. 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: A. Trendelenburg’s position with the legs in stirrups B. Semi-Fowler position with a pillow under the knees C. Prone position with the legs separated and elevated D. Supine position with a wedge under the right hip