Answered Maternity - Intrapartum NCLEX question Exam 2. Latest update. 99% pass rate.

Answered Maternity - Intrapartum NCLEX question Exam 2. Latest update. 99% pass rate. Document Content and Description Below A 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 assoc iated with abruptio placentae? Select all that apply. - ☑☑Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Increased uterine resting tone on fetal monitoring Rationale: In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa A nurse is developing 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? 1. Monitoring fetal status 2. Providing comfort measures 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor - ☑☑1. monitoring fetal status Rationale: The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority. A nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should assess that the amniotic fluid is normal if it has which characteristics? 1. Clear and dark amber color 2. Light green color with no odor 3. Thick white color with no odor 4. Straw-colored, with flecks of vernix - ☑☑4. Straw-colored, with fleck of vernix Rationale: Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin watery consistency and may have a mild odor. The other options are not descriptions of normal amniotic fluid 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. Which is the initial nursing action? 1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 2. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. 3. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min. - ☑☑1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. Rationale: If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is applied to the mother. The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Administer magnesium sulfate intravenously. 4. Assess the blood pressure and fetal heart rate. - ☑☑2. Clear and maintain an open airway. Rationale: The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow administer oxygen by face mask, administer magnesium sulfate intravenously, asses the blood pressure and fetal heart rate A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment finding would indicate the presence of concealed bleeding? 1. Back pain 2. Heavy vaginal bleeding 3. Increase in fundal height 4. Early deceleration on the fetal heart monitor - ☑☑3. Increase in fundal height Rationale: The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the mother's reflexes 2. Taking the mother's temperature 3. Taking the mother's apical pulse 4. Monitoring the mother's blood pressure - ☑☑4. Monitoring the mother's blood pressure Rationale: A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. 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? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques. - ☑☑1. Notify the health care provider (HCP). Rationale: A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified A 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? 1. Hypotonic 2. Precipitate 3. Hypertonic 4. Preterm labor - ☑☑1. Hypotonic Rationale: Hypotonic labor contractions are short, irregular, weak, and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation 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? 1. Delivery of the fetus Show Less Last updated: 8 months ag