EVOLVE MATERNITY/ MATERNITY
EVOLVE EXAM | NEWEST ACTUAL
EXAM COMPREHENSIVE QUESTIONS
AND VERIFIED ANSWERS GRADED A+ |
100% PASS | 2024 UPDATE!
The membranes of a client who is at 39 weeks' gestation have ruptured
spontaneously. Examination in the emergency department reveals that
her cervix is dilated 4 cm and 75% effaced, and the fetal heart rate is
136 beats/min. She and her partner are admitted to the birthing unit.
What should the nurse do upon their arrival?
1
Settle the client in bed and attach an external fetal monitor.
2
Have the client undress while taking her history from her partner.
3
Introduce the staff nurses to the couple and try to make them feel
welcome.
4
Ask the couple to wait in the examining room while notifying the health
care provider. - ✔✔✔ Correct Answer > 3
,The client is in the first stage of labor; she and the fetus were assessed
earlier, and both are stable. At this time the priority of care is the
establishment of a trusting relationship with the client and her partner.
This will help allay their anxiety. Putting the client in bed and attaching
an external fetal monitor may be necessary later; however, it is not the
priority. The history should be taken from the client as long as she is
capable of providing it. Asking the couple to wait in the examining room
while notifying the health care provider is not a priority; the provider
may have been notified already.
During labor a client who is receiving epidural anesthesia has an
episode of severe nausea, and her skin becomes pale and clammy.
What is the immediate nursing action?
1
Elevating the legs
2
Notifying the practitioner
3
Checking for vaginal bleeding
4
Monitoring the frequency of contractions - ✔✔✔ Correct Answer > 1
Maternal hypotension is a common complication of epidural
anesthesia, and nausea is one of the first clues that it has occurred;
elevating the lower extremities restores blood volume to the central
circulation. If signs and symptoms do not abate after elevation of the
legs, the practitioner should be notified. Checking for vaginal bleeding
,and monitoring the frequency of contractions are not specific
observations associated with the administration of anesthesia; they are
each part of the general nursing care during labor.
A client is receiving an intravenous piggyback infusion of oxytocin
(Pitocin) to augment labor. The nurse identifies three contractions
lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is
followed in response to this observation. List in order of priority the
nursing actions that should be taken.
1.
Check the fetal heart rate (FHR).
2.
Stop the piggyback infusion.
3.
Notify the health care provider.
4.
Administer oxygen by way of facemask.
5.
Document the responses of the client and fetus.
, 6.
Determine whether the contractions have diminished. - ✔✔✔ Correct
Answer > 236145
When tetanic contractions occur, the nurse should first stop the
oxytocin infusion; this should relax the uterus and prevent uterine
tetany and rupture. The FHR should be checked to determine the effect
of the tetanic contractions on the fetus. After the FHR has been
assessed, the maternal response to the interruption of the infusion
should be assessed. Once these measures have been implemented, the
primary care giver should be notified. Fetal well-being will improve
when oxygen is administered. After emergency measures have been
taken, the client's and fetus's responses should be documented.
After a client has been in labor for 6 hours at home, she is admitted to
the birthing room. The client is dilated 5 cm and at −1 station. In the
next hour her contractions gradually become irregular and are more
uncomfortable. Which possibility should the nurse consider first?
1
The client is in false labor.
2
The client has a full bladder.
3
There is uterine dysfunction.
4
EVOLVE EXAM | NEWEST ACTUAL
EXAM COMPREHENSIVE QUESTIONS
AND VERIFIED ANSWERS GRADED A+ |
100% PASS | 2024 UPDATE!
The membranes of a client who is at 39 weeks' gestation have ruptured
spontaneously. Examination in the emergency department reveals that
her cervix is dilated 4 cm and 75% effaced, and the fetal heart rate is
136 beats/min. She and her partner are admitted to the birthing unit.
What should the nurse do upon their arrival?
1
Settle the client in bed and attach an external fetal monitor.
2
Have the client undress while taking her history from her partner.
3
Introduce the staff nurses to the couple and try to make them feel
welcome.
4
Ask the couple to wait in the examining room while notifying the health
care provider. - ✔✔✔ Correct Answer > 3
,The client is in the first stage of labor; she and the fetus were assessed
earlier, and both are stable. At this time the priority of care is the
establishment of a trusting relationship with the client and her partner.
This will help allay their anxiety. Putting the client in bed and attaching
an external fetal monitor may be necessary later; however, it is not the
priority. The history should be taken from the client as long as she is
capable of providing it. Asking the couple to wait in the examining room
while notifying the health care provider is not a priority; the provider
may have been notified already.
During labor a client who is receiving epidural anesthesia has an
episode of severe nausea, and her skin becomes pale and clammy.
What is the immediate nursing action?
1
Elevating the legs
2
Notifying the practitioner
3
Checking for vaginal bleeding
4
Monitoring the frequency of contractions - ✔✔✔ Correct Answer > 1
Maternal hypotension is a common complication of epidural
anesthesia, and nausea is one of the first clues that it has occurred;
elevating the lower extremities restores blood volume to the central
circulation. If signs and symptoms do not abate after elevation of the
legs, the practitioner should be notified. Checking for vaginal bleeding
,and monitoring the frequency of contractions are not specific
observations associated with the administration of anesthesia; they are
each part of the general nursing care during labor.
A client is receiving an intravenous piggyback infusion of oxytocin
(Pitocin) to augment labor. The nurse identifies three contractions
lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is
followed in response to this observation. List in order of priority the
nursing actions that should be taken.
1.
Check the fetal heart rate (FHR).
2.
Stop the piggyback infusion.
3.
Notify the health care provider.
4.
Administer oxygen by way of facemask.
5.
Document the responses of the client and fetus.
, 6.
Determine whether the contractions have diminished. - ✔✔✔ Correct
Answer > 236145
When tetanic contractions occur, the nurse should first stop the
oxytocin infusion; this should relax the uterus and prevent uterine
tetany and rupture. The FHR should be checked to determine the effect
of the tetanic contractions on the fetus. After the FHR has been
assessed, the maternal response to the interruption of the infusion
should be assessed. Once these measures have been implemented, the
primary care giver should be notified. Fetal well-being will improve
when oxygen is administered. After emergency measures have been
taken, the client's and fetus's responses should be documented.
After a client has been in labor for 6 hours at home, she is admitted to
the birthing room. The client is dilated 5 cm and at −1 station. In the
next hour her contractions gradually become irregular and are more
uncomfortable. Which possibility should the nurse consider first?
1
The client is in false labor.
2
The client has a full bladder.
3
There is uterine dysfunction.
4
