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Intrapartum Questions with with complete solution

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Intrapartum Questions with with complete solution Intrapartum A client with intrauterine growth restriction is admitted to the labor and birth unit and started on an I.V. infusion of oxytocin. Which aspect of the client's care plan should the nurse revise? - correct answer Allowing the clien...

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  • August 7, 2024
  • 10
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • intrapartum
  • intrapartum questions with with complete solutio

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  • NCC ELECTRONIC
  • NCC ELECTRONIC

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Intrapartum
A client with intrauterine growth restriction is admitted to the labor and birth
unit and started on an I.V. infusion of oxytocin. Which aspect of the client's
care plan should the nurse revise? - correct answer ✔Allowing the client to
ambulate as tolerated




Because the fetus is at risk for complications, frequent and close monitoring is
necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully
titrating the oxytocin, monitoring vital signs, including fetal well-being, and
assisting with breathing exercises are appropriate actions to include in the
care plan.


For the past 8 hours, a 20-year-old primigravid client in active labor with intact
membranes has been experiencing regular contractions. The fetal heart rate
is 136 bpm with good variability. After determining that the client is still in the
latent phase of labor, the nurse should observe the client for: - correct answer
✔exhaustion.


The normal length of the latent stage of labor in a primigravid client is 6 hours.
If the client is having prolonged labor, the nurse should monitor the client for
signs of exhaustion as well as dehydration. Hypotonic contractions, which are
painful but ineffective, may be occurring. Oxytocin augmentation may be
necessary. Chills and fever are manifestations of an infection and are not
associated with a prolonged latent phase of labor. Fluid overload can occur
from rapid infusion of intravenous fluids administered if the client is
experiencing hemorrhage or shock. It is not associated with prolonged latent
phase. The client's membranes are intact, so it would be difficult to assess
meconium staining of the fluid. Meconium-stained fluid is associated with fetal
distress, and this fetus appears to be in a healthy state, as evidenced by a
fetal heart rate within normal range and good variability.

, A primigravid client at 34 weeks' gestation is experiencing contractions every
3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50%
effaced. While the nurse is assessing the client's vital signs, the client says, "I
think my bag of water just broke." Which intervention would the nurse do first?
- correct answer ✔Check the status of the fetal heart rate.


The health care provider (HCP) prescribes intermittent fetal heart rate
monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation in
the first stage of labor. The nurse should monitor the client's fetal heart rate
pattern at which interval? - correct answer ✔every 30 minutes during the
active phase


The first stage of labor is categorized into three phases: latent, active, and
transition. During the active stage of labor, intermittent fetal monitoring is
performed every 30 minutes to detect changes in fetal heart rate such as
bradycardia, tachycardia, or decelerations in a low risk labor. If complications
develop, more frequent or continuous electronic fetal monitoring may be
needed. During the latent phase, intermittent monitoring is usually performed
every 1 hour because contractions during this time are usually less frequent.
During the transition phase, intermittent monitoring is performed every 5
minutes because the client is getting closer to the birth of the baby. Pushing
occurs in stage II of labor, and monitoring continues to occur every 5 to 15
minutes.


A laboring client is restless and moving frequently in the bed. She is
uncomfortable but refuses pain medication when offered. Which of the
following responses from the nurse is most helpful? - correct answer ✔Stand
next to her at the side of the bed.


The client is alone and is progressing well in labor, as evidenced by her
restless behaviors. She is refusing analgesia but will benefit from the 1:1
nursing care model if she is aware that the nurse is attending her at the
bedside. Standing behind her will not provide a sense of nursing presence.

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