NUR 335 Intrapartum Nursing Assessment (Answered) Latest

Placental separation The nurse is preparing to care for a client in labor. The health care provider (HCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse should ensure that which is implemented before the beginning of the infusion?{correct ans} 3. Continuous electronic fetal monitoring The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the health care provider (HCP)? Select all that apply.{correct ans} 1. Clear, dark amber amniotic fluid 3. Light green amniotic fluid with no odor 4. Thick white amniotic fluid with no odor The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?{correct ans} 1. Monitoring fetal status The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?{correct ans} 2. The passage of meconium The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention?{correct ans} 1. Provide pain relief measures. The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?{correct ans} 2. Place the client in Trendelenburg's position. The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action?{correct ans} 1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?{correct ans} 1. Delivery of the fetus The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?{correct ans} 1. Hypotonic The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?{correct ans} 2. Continue to monitor the client. A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action?{correct ans} 4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply.{correct ans} 1. Station 2. Dilation 3. Effacement The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply.{correct ans} 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "boardlike" abdomen 5. 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 ans} 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 ans} 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 ans} 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 ans} 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 ans} 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 ans} 3.