When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating. 1. Aft...
NSG 321 Exam 2 Questions and
Complete Solutions
When during the latent phase of labor should the nurse assess the fetal heart
pattern of a low-risk woman, G1 P0000? Select all that apply.
1. After vaginal exams.
2. Before administration of analgesics.
3. Periodically at the end of a contraction.
4. Every ten minutes.
5. Before ambulating. ✅1. After vaginal exams -
2. before administration of analgesics
3. periodically at the end of a contraction
5. Before ambulating
At each of the times noted in the scenario—vaginal exam, analgesic administration,
contraction, and ambulation—either the cord could be compressed or the baby could be
compromised.
Baby should be checked every hour not ten minutes
A nurse is caring for a laboring woman who is in transition. Which of the following
signs/symptoms would indicate that the woman is progressing into the second stage
of labor? Select all that apply.
1. Bulging perineum.
2. Increased bloody show.
3. Spontaneous rupture of the membranes.
4. Uncontrollable urge to push.
5. Inability to breathe through contractions. ✅1. bulging perineum indicates
progression
2. increased bloody show increases as woman enter the second stage
4. dilated cervix and bulging perineum will make the mother want to push
3. The membrane can rupture at any time
5. Mother's ability to breathe is dependent on pain than on phases of labor
The nurse enters a laboring client's room. The client is complaining of intense back
pain with each contraction. The nurse concludes that the fetus is likely in which of
the following positions?
1. Mentum anterior.
2. Sacrum posterior.
3. Occiput posterior.
4. Scapula anterior. ✅3. Occiput posterior
, If you imagine a baby in occiput posterior they would be lying on the coccyx of the
mother which can be painful
When performing Leopold's maneuvers, the nurse notes that the fetus is in the left
occiput anterior position. Where should the nurse place a fetoscope best to hear
the fetal heart beat?
1. Left upper quadrant.
2. Right upper quadrant.
3. Left lower quadrant.
4. Right lower quadrant. ✅3. Left lower quadrant
A client, who is 7 cm dilated and 100% effaced, is breathing at a rate of 30 breaths
per minute during contractions. Immediately after a contraction, she complains of
tingling in her fingers with some lightheadedness. Which of the following actions
should the nurse take at this time?
1. Assess the blood pressure.
2. Have the woman breathe into a bag.
3. Turn the woman onto her side.
4. Check the fetal heart rate. ✅2. Have the woman breathe into a bag because she is
hyperventilating. Symptoms reside if she rebreathes in her exhalations.
A woman, G2 P0101, 5 cm dilated and 30% effaced, is doing first-level Lamaze
breathing with contractions. The nurse detects that the woman's shoulder and face
muscles are beginning to tense during the contractions. Which of the following
interventions
should the nurse perform first?
1. Encourage the woman to have an epidural.
2. Encourage the woman to accept intravenous analgesia.
3. Assist the woman in changing position.
4. Urge the woman to perform the next level breathing. ✅4. Urge the woman to
perform the next level of breathing
This woman is beginning to enter the active phase of labor, the first phase breathing is
no longer effective. It is important to support her actions.
The nurse documents in a laboring woman's chart that the fetal heart is being
"assessed via intermittent auscultation." To be consistent with this statement, the
nurse, using a Doppler electrode, should assess the fetal heart at which of the following
times?
1. After every contraction.
2. For 10 minutes every half hour.
3. Periodically during the peak of contractions.
4. For 1 minute immediately after contractions. ✅4. Intermittent auscultation should be
performed for 1 full minute after contractions end.
Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and
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