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?
1.The client begins to expel clear vaginal fluid
2.The contractions are regular
3.The membranes have ruptured
4.The cervix i...
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?
1.The client begins to expel clear vaginal fluid
2.The contractions are regular
3.The membranes have ruptured
4.The cervix is dilated completely - ANS 4. 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:
1.Place the mother in the supine position
2.Document the findings and continue to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion - ANS 3. Late decelerations are due to
uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during
the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine
position is avoided because it decreases uterine blood flow to the fetus. The client should be
turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An
intravenous
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?
1.Fetal heart rate of 180 beats per minute
2.White blood cell count of 12,000
3.Maternal pulse rate of 85 beats per minute
4.Hemoglobin of 11.0 g/dL - ANS 1. A normal fetal heart rate is 120-160 beats per minute.
A count of 180 beats per minute could indicate fetal distress and would warrant physician
notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the
hemodilution caused by an increase in plasma volume during pregnancy.
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:
1.Trendelenburg's position with the legs in stirrups
2.Semi-Fowler position with a pillow under the knees
, 3.Prone position with the legs separated and elevated
4.Supine position with a wedge under the right hip - ANS 4. Vena cava and descending
aorta compression by the pregnant uterus impedes blood return from the lower trunk and
extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus
and the fetus. The best position to prevent this would be side-lying with the uterus displaced off
of abdominal vessels. Positioning for abdominal surgery necessitates a supine position;
however, a wedge placed under the right hip provides displacement of the uterus.
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:
1.Noting if the heart rate is greater than 140 BPM
2.Placing the diaphragm of the Doppler on the mother abdomen
3.Performing Leopold's maneuvers first to determine the location of the fetal heart
4.Palpating the maternal radial pulse while listening to the fetal heart rate - ANS 4. The
nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal
heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may
mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the
examiner locate the position of the fetus but will not ensure a distinction between the two rates.
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?
1.Three contractions occurring within a 10-minute period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated between contractions
4.Increased urinary output - ANS 2. A normal fetal heart rate is 120-160 BPM. Bradycardia
or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin.
The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute
period.
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?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside - ANS 2. Continuous electronic fetal
monitoring should be implemented during an IV infusion of Pitocin.
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?
1.Encourage the client's coach to continue to encourage breathing exercises
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