Stages of Labor
In Stage 1 of Labor the cervix dilates..
A. 1-3cm
B. 4-7cm
C. 1-10cm
D. 7-10cm
A. 1-3cm
The nurse is monitoring a client in active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?
A. Hypotonic
B. Precipitous
C. Hypertonic
D. Preterm labor
A. Hypotonic
The nurse is reviewing the record of a client in the labor room and notes that the health care provider had documented the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area?
A. 1 inch below the coccyx
B. 1 inch below the iliac crest
C. 1 cm above the ischial spine
D. 1 fingerbreadth below the symphysis pubis
C. 1 cm above the ischial spine
A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as:
A. Scant
B. Light
C. Heavy
D. Excessive
C. Heavy
The patient is scheduled to begin induction at 0600. The patient will be receiving misoprostol vaginally and beginning a oxyctocin drip. What is the mother at an increased risk for due to the oxytocin?
A. Torn uterus
B. Uterine Tachysystole
C. Postpartum Hemorrhage
D. Engorgement
B. Uterine Tachysystole
True or False: Stage 2 of labor begins with the delivery of the baby and ends with the delivery of the placenta
False
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?
A. "I won't be in labor until my baby drops."
B. "My contractions will be felt in my abdominal area."
C. "My contractions will not be as painful if I walk around."
D. "My contractions will increase in duration and intensity."
D. "My contractions will increase in duration and intensity."
The nurse is doing her first assessment on a patient she has just received report on. During the assessment the nurse finds the mother is 5cm dilated, 90% effaced and 0 station. What stage of labor is this mother in?
A. Transitional
B. Latent
C. Active
D. Second
C. Active
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?
A. Administer oxygen via face mask
B. Place the mother in a supine position
C. Increase the rate of the oxytocin intravenous infusion
D. Document the findings and continue to monitor the fetal patterns
A. Administer oxygen via face mask
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on assessment?
A. Proteinuria of 3+
B. Respirations of 10 breaths per minute
C. Presence of deep tendon reflexes
D. Serum magnesium level of 6 milliequivilents per liter
B. Respirations of 10 breaths per minute
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
A. The contractions are regular.
B. The membranes have ruptured
C. The cervix is completely dilated
D. The client starts to expel clear vaginal fluid
C. The cervix is completely dilated
A client arrives at birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy?
A. less pressure on her cervix
B. decreased number of contractions
C. increased efficiency of contractions
D. the need for increased maternal blood pressure monitoring
C. increased efficiency of contractions
A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.
A. Less pressure on her cervix
B. Decreased number of contractions
C. Increased efficiency of contractions
D. The need for increased maternal blood pressure monitoring
E. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
C. Increased efficiency of contractions
E. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
The 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 electronic fetal monitor, what is the next nursing action?
A. Identify the types of accelerations
B. Assess the baseline fetal heart rate
C. Determine the intensity of the contractions
D. Determine the frequency of the contractions
B. Assess the baseline fetal heart rate
The postpartum nurse expects to administer which first-line pain medication to a mom that just delivered her second baby vaginally?
A. Tylenol
B. Motrin
C. Oxycodone
D. Senokot
B. Motrin
The nurse recognizes that the client is in latent phase of the first stage of Labor. This phase is best described as lasting from:
A. Undilated cervix to a 2cm dilation
B. Onset of contractions to 4cm
C. Cervix is dilated 4cm to dilation of 8cm
D. No contraction to contractions every 3 minutes
B. Onset of contractions to 4cm
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 per minute. Which nursing action is most appropriate?
A. Notify the PHCP
B. Continue monitoring the fetal heart rate
C. Encourage the client to continue pushing with each contraction
D. Instruct the client's coach to continue to encourage breathing techniques
A. Notify the PHCP
The 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 action is the most appropriate?
A. Notify the health care provider of the findings
B. Reposition the mother and check the monitor for changes in fetal tracing
C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen
D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well being
D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well being
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
A. Variability
B. Accelerations
C. Early decelerations
D. Variable decelerations
D. Variable decelerations
Which of the following are accurate nursing considerations for fentanyl administration to a laboring mom?
A. Do not use within 2 hours of delivery
B. Closely monitor FHR after the first administration of fentanyl
C. Hold next fentanyl dose if FHR does not return to baseline within 30 mins
D. May give during earliest stages of labor and throughout as long as vitals are stable.
E. Maternal RR above 12
A, C, E
The nurse, working on a labor and delivery unit, anticipates active labor for a primagravida will last how long?
A. 16-18h
B. 12-14h
C. 8-10h
D. 4-6h
D. 4-6h
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action?
A. Notify the HCP
B. Discontinue the infusion of oxytocin
C. Place oxygen on at 8 to 10 L/minute via face mask
D. Contact the client's primary support person(s) if not currently present
B. Discontinue the infusion of oxytocin
The primary nurse performs a vaginal examination and finds a prolapsed cord. The nurses priority action will be to:
A. Give medication to hasten a vaginal delivery
B. Keep the client in a back-lying position
C. Make arrangements for an emergency cesarean section
D. Get the cord back to its original location
C. Make arrangements for an emergency cesarean section
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider?
A. Hemoglobin of 11 g/dL
B. Fetal heart rate of 180 beats per minute
C. Maternal pulse rate of 85 beats per minute
D. White blood cell count of 12,000
B. Fetal heart rate of 180 beats per minute
A client in preterm labor at 31 weeks who is dilated to 4 centimeters has been started on magnesium sulfate and contraction have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?
A. Bethamethasone
B. Nubain
C. RhoGam
D. Cervidil vaginal insert
A. Bethamethasone