Which client in the Labor Delivery Recovery and Postpartum Unit should the nurse see first

The nurse admits a client to the labor and delivery unit who suspects she is in labor. Which of the following characteristics would indicate the client is in true labor?

contractions are regular, becoming stronger and lasting longer

The nurse is caring for a client who is 3 cm dilated and 80% effaced, with her fetus at -1 station. The client states she is beginning to experience discomfort with each contraction. Which of the following breathing techniques would be appropriate?

The following data has been recorded on the client's chart: 5/80/+1. How does the nurse interpret this data?

The cervix is 5 cm dilated, 80% effaced, and the presenting part is 1 cm above the ischial spine.

The nurse is checking the client's chart and notes the abbreviation ROA. The nurse knows this means that the presenting part is:

occiput. The fetal position is at the right side of the maternal pelvis, occiput directed toward anterior (front)

The nurse is caring for a Mexican client during labor. Which of the following interventions should the nurse be prepared to perform?

Ask the client if she needs pain medication when she reaches the 2nd stage of labor. Mexican clients may be stoic about discomfort until the 2nd stage of labor, then they may request pain relief. The father and female relatives may be present.

You are caring for a client who delivered her baby by cesarean section 15 minutes ago and is in the recovery room. Her vital signs are stable but she is not yet awake. What is the nursing priority for this client?

Maintaining a patent airway

Precipitous labor can be defined as labor that lasts:

Your client has been in labor for 2 hours and suddenly states, "The baby is coming." What should be your first action?

Check to see if the fetus is crowning

Which of the following side effects can occur following the insertion of an epidural catheter?

Preterm labor is the onset of regular contractions between the 20th and 37th week that cause changes in the cervix 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?

The cervix is dilated completely

The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.

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

Administer oxygen via face mask

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?

Fetal heart rate of 180 beats per minute

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:

Supine position with a wedge under the right hip

A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:

Palpating the maternal radial pulse while listening to the fetal heart rate

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

A fetal heart rate of 90 beats per minute

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion?

Continuous electronic fetal monitoring

A 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 BPM. Which of the following nursing actions is most appropriate?

Notify the physician or nurse mid-wife

A 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 of the following actions is most appropriate?

Document the findings and tell the mother that the monitor indicates fetal well-being

A 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 monitor, the initial nursing assessment is which of the following?

Assessing the baseline fetal heart rate

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at -1 station. The nurse determines that the fetal presenting part is:

1 cm above the ischial spine

A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following?

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have:

Increased efficiency of contractions

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?

A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is:

Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus

A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as:

A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes.

Stop of Pitocin infusion Check the client's blood pressure and heart rate Perform a vaginal examination Administer oxygen by face mask at 8 to 10 L/min Reposition the client

A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition?

Oxytocin (Pitocin) infusion

A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to:

Provide pain relief measures

A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority?

Monitoring fetal heart rate

A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor:

So that each fetal heart rate is monitored separately

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?

Changes in the shape of the uterus

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action?

Place the client in Trendelenburg's position

A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?

Swelling in the calf of one leg

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

Uterine tenderness/pain Acute abdominal pain

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order?

Obtain equipment for a manual pelvic examination

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for:

client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be:

Auscultating the fetal HR

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is

After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed:

Below the umbilicus on the right side

The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction:

To the beginning of the next contraction

The physician asks the nurse the frequency of a laboring client's contractions. The he nurse observes the client's amniotic fluid and decides that it appears normal, because it is:

Clear, almost colorless, and containing little white specks

At 38 weeks' gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should:

Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:

Change the client's position

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is:

The breathing technique that the mother should be instructed to use as the fetus' head is crowning is:

During the period of induction of labor, a client should be observed carefully for signs of:

The relaxation phase between contractions is important because

the contractions can interfere with fetal oxygenation

The nurse recognizes that the contraction duration and interval that could result in fetal compromise is:

duration >90 seconds, interval <60seconds

Vaginal examination reveals the presenting part is the infants head, which is well flexed on his or her chest. This presentation is referred to as:

While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. The nurse’s most informative response would be that the woman should come when she:

Thinks her membranes have ruptured

Contractions during the first stage of labor:

dilate and efface the cervix

During the 4th stage of labor, the nurse encourages the mother to void because

a full bladder may predispose the mother to uterine hemorrhage

If the nurse observes on the fetal monitor a pattern of a 15 beat increase in the fetal heart rate that lasts 15-20 seconds the nurse knows that this pattern is indicative of a

The most important nursing activity during the 4th stage of labor is to assess for

One hour postdelivery the nurse notes that the new mother has saturated three perineal pads, the nurse should:

check the fundus for position and firmness

To relieve perineal bruising and edema following delivery, the nurse should place an ice pack on the area for

Which drug should be immediately available for emergency use when a woman receives narcotics during labor?

Labor pains are influenced by

Chemical substance produced in the body that acts as natural pain relievers:

Woman who is 6cm dilated has the urge to push. Nurse should instruct woman to

blow in short breaths during the contraction

Several hours into labor, a woman complains of blurred vision, numbness and tingling of her hands and mouth. The nurse recognizes these symptoms as:

hyperventilation; when woman hyperventilates, help her breathe into her cupped hand

After the physician discussed general anesthesia with a woman in labor, the nurse determines the woman understood the explanation when she says food and fluids are restricted for several hours prior to delivery to prevent:

A woman received a subarachnoid block before delivery. In order to prevent the associated side effect of this type of anesthesia, the nurse would include in the teaching plan that the patient should:

Lie flat on her back for several hours.

The nurse coaches the primigravida not to bear down until the cervix is completely dilated because premature bearing down can cause:

A potential adverse effect of pudendal block is:

The release of ______________ during labor may explain why women often need smaller doses of an analgesic or anesthetic than might be expected in a similarly painful experience.

A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?

Labor is five essential factors, one of these is the passenger (fetus) the other four are:

passageway, contractions, placental position and function, psychological response

A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates titanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin.  The woman is in a side-lying position, and her vital signs are stable and fall within a normal range.  Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to:

While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy?

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?

A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartal psychological adaptation that the client would be in would be termed which of the following?

While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?

Notify the physician immediately

A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?

For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? 

The membranes must rupture

A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense:

After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?

Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and output closely during Oxytocin administration?

Oxytocin causes water intoxication

The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?

After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:

Lubricate her nipples with expressed milk before feeding

Which woman is most at risk for bladder distention after a normal vaginal delivery?

A woman who had epidural anesthesia

What is the nurse's chief concern when a mother who delivered 2 hours ago has a blood pressure change from 112/70 to 142/94?

The nurse is assessing a postpartum client who gave birth 10 hours ago. What assessment finding would need further investigation by the nurse?

fundus deviated to the right

The nurse assesses an 8-hour-postpartum client. Findings include lochia rubra, with a firm fundus at the level of the umbilicus. What nursing action is indicated?

Document and continue to monitor

The nurse is caring for four high-risk postpartum clients. Which predisposing conditions place a client at risk for developing hemorrhage? Select all that apply.

Precipitous labor, Twin gestation

A nurse is caring for four postpartum clients. Which have an increased risk of thrombophlebitis? Select all that apply.

the client with a c-section, the client with preclamspia

What laboratory values should the nurse report to the credentialed practitioner immediately when caring for a patient who had a C-section yesterday?

hematocrit of 29%, sodium of 129. Leukocytosis after delivery is normal.

Normal findings for primipara holding her new infant

fingertip exploration, use of en face position, reluctance to change diapers, talking in a high-pitched voice. Voicing disappointment in the infant’s sex does not indicate normal

What suggestion should the nurse provide to the client who complains of severe after pains? 

A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal massage. The client's fundus is firm but elevated and deviated to the right. What would be the most appropriate nursing action?

A nurse is preparing a postpartum client for discharge. The client's medical record reveals the following data: headaches relieved by aspirin, drinks one glass of wine per day, walks 2 miles each day, and smokes a half a pack of cigarettes per day. While instructing the client about the medication methylergonovine maleate (Methergine), the nurse cautions the client to avoid:

A 24-hour-postpartum client who had a cesarean birth with general anesthesia complains of abdominal discomfort and gas pains. What is the most appropriate nursing intervention? 

position client on left side

A nurse is caring for a postpartum client. Which finding would make the nurse suspect endometritis in this client?

fever over 38C, beginning 2 days postpartum

A nurse is performing an assessment on a post-term infant. Which physical characteristic should the nurse expect to observe?

A-peeling of the skin. The postterm infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather like skin over the body, which is called desquamation

A post-term infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of:

meconium aspiration syndrome

uterus shrinking postpartum

Nurse Lucia is aware that lochia normally progresses in which of the following patterns?

Rubra, serosa, alba (clear white)

When caring for a client who has had a cesarean section, nurse Annie is aware that the following actions is not appropriate?

Removing the initial dressing for incision inspection

Nurse Tristan is aware that the following would be inappropriate to include in the plan of care for a client during the fourth stage of labor?

Catheterization to protect the bladder from trauma

Nurse Honey is assessing a client on the 2nd postpartum day. Under normal circumstances, the tone and location of the client’s fundus is

firm and two fingerbreadths below the umbilicus

Nurse Tanya is aware that the following is the most important aspect of nursing care in the postpartum period?

Supporting the mother’s ability to successfully feed and care for her infant

After a vaginal delivery, Jasmine complains of perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction?

Contract your buttocks before sitting or rising

Nurse Luisa is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client’s fundus?

One fingerbreadth below the umbilicus

One day after a client delivers a neonate, nurse Beatriz performs a postpartum assessment. At this time, the nurse expects to find:

Jackie, a postpartum client is ready for discharge. During discharge preparation, the nurse should instruct her to report which of the following to her primary health care provider?

Redness, warmth, and pain in the breastsàmastitis

What task by the RN should be performed first?

Which assignment would be appropriate for the nurse to delegate to an unlicensed assistive personnel UAP?

Which task could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel?

Which roles could the nurse assign to unlicensed assistive personnel in caring for a client with a cast quizlet?