2024 LATEST Intrapartum EXAM

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. - CORRECT ANSWER 3. A gravida II who has just been diagnosed with dead fetus syndrome 5. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. - CORRECT ANSWER 3. The cervix is dilated completely. 5. The spontaneous urge to push is initiated from perineal pressure. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? - CORRECT ANSWER 1. Administer oxygen via face mask. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? - CORRECT ANSWER 2 .Fetal heart rate of 180 beats/minute The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer. - CORRECT ANSWER 3 A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. - CORRECT ANSWER 3. Increased efficiency of contractions 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? - CORRECT ANSWER 4. Variable decelerations A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? - CORRECT ANSWER 1.Supine position with a wedge under the right hip The 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 beats/minute. Which nursing action is most appropriate? - CORRECT ANSWER 1. Notify the health care provider (HCP). The 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 action is most appropriate? - CORRECT ANSWER 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. The 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 electronic fetal monitor, what is the next nursing action? - CORRECT ANSWER 2. Assess the baseline fetal heart rate. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? - CORRECT ANSWER 4. "My contractions will increase in duration and intensity." Which assessment following an amniotomy should be conducted first? - CORRECT ANSWER 3. Fetal heart rate pattern The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? - CORRECT ANSWER 2. Rest between contractions The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? - CORRECT ANSWER 2. Discontinue the infusion of oxytocin. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? - CORRECT ANSWER 2. Uterine tenderness The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? - CORRECT ANSWER 2. Obtain equipment for a manual pelvic examination. The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. - CORRECT ANSWER 1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? - CORRECT ANSWER 4. Persistent nonreassuring fetal heart rate The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? - CORRECT ANSWER 1. Provide pain relief measures. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? - CORRECT ANSWER 3. Perform a vaginal examination every shift. 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? - CORRECT 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. - CORRECT ANSWER 4. Bright red vaginal bleeding