Nursing Care During Labor & Childbirth
A nurse is assisting with the care of a client in labor. Her cervix is dilated to 9 cm, and she has strong contractions q2min that last 75 sec. The nurse should recognize that this client is in which of the following phases or stages of labor?
a.) Latent phase of first stage
b.) Active phase of first stage
c.) Second stage
d.) Transition phase of first stage
d.) Transition phase of first stage
A nurse is assisting with the care of a client in active labor and notes late decelerations on the fetal monitor. Which of the following actions should the nurse take?
a.) Administer methylprostaglandin IM
b.) Encourage the client to use the shower
c.) Place the client in a supine position
d.) Apply O2 at 10L/min via nonrebreather face mask
d.) Apply O2 at 10L/min via nonrebreather face mask
A nurse in a clinic is reinforcing teaching with a client who is 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make?
a.) "Your provider will insert a hand into your uterus and turn your baby around."
b.) "You will receive a medication to relax your uterus prior to the procedure."
c.) "This procedure will be performed in the clinic at your next visit."
d.) "Your baby's heartbeat will be monitored occasionally throughout the procedure."
b.) "You will receive a medication to relax your uterus prior to the procedure."
The client often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the provider.
A nurse is collecting data from a client who delivered vaginally 8 hrs. ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first?
a.) Administer analgesia
b.) Administer carboprost IM
c.) Assist the client to the toilet
d.) Obtain a blood specimen to test Hct and Hgb levels
c.) Assist the client to the toilet
A nurse on a postpartum unit is assisting w/ the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first?
a.) Provide fundal massage for the client.
b.) insert an indwelling urinary catheter for the client.
c.) administer methylergonovine IM to the client.
d.) administer O2 via nonrebreather face mask to the client.
a.) Provide fundal massage
The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should take is to provide fundal massage to increase uterine muscle tone and express blood clots from the uterus, which will decrease bleeding.
A nurse is assisting with care for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions?
a.) Palpating the firmness of the uterus during a contraction
b.) Calculating the time from the end of a contraction to the beginning of the next
c.) Measuring the time from the beginning of a contraction to the end of that same contraction
d.) Evaluating the amount of time from the beginning of a contraction to the beginning of the next contraction
d.) Evaluating the amount of time from the beginning of a contraction to the beginning of the next contraction
A nurse is assisting with the care of a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal HR tracing. Which of the following actions should the nurse take?
a. Discontinue the oxytocin infusion and apply oxygen
b. Increase oxytocin infusion rate by 2 mu/min
c. Administer terbutaline 0.25 mg subcut
d. Assist the client into a side-lying position and continue to monitor
d. Assist the client into a side-lying position and continue to monitor
Category 1 fetal heart rate tracing is an expected finding and does not represent fetal distress. By placing the client in a side-lying position, this optimizes uteroplacental perfusion. Continue to monitor for another 10 min to determine whether tachysystole resolves.
A nurse is caring for a client who is postpartum and reports abdominal pain due to flatus. Which of the following actions should the nurse take?
a.) Assist the client to ambulate in the hallway.
b.) Encourage the client to increase fiber intake.
c.) Administer a dose of laxative medication to the client.
d.) Increase the client's fluid intake.
a.) Assist the client to ambulate in the hallway.
Ambulation and rocking in a rocking chair stimulate the passage of flatus and stool.
A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include?
a.) Instruct the client to discontinue feeding from the affected breast.
b.) Tell the client to wear an underwire bra.
c.) Instruct the client to apply warm compresses to the affected breast.
d.) Administer an antiviral medication.
c.) Instruct the client to apply warm compresses to the affected breast.
The nurse should instruct the client to apply warm compresses to the breast, which will decrease inflammation and edema. This will enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth.
A nurse is assisting with the preparation of a laboring client who is scheduled to receive an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make?
a.) "This type of monitoring is necessary for timing the frequency of your contractions."
b.) "This type of monitoring is noninvasive, so it is the best way to monitor your labor contractions."
c.) "This type of monitor allows us to evaluate your baby's HR while you are in labor."
d.) "This type of monitoring will allow us to measure the intensity of your contractions."
d.) "This type of monitoring will allow us to measure the intensity of your contractions."
A nurse is caring for a client who is 32 hrs postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide?
a.) "Call me so I can check your baby's latch the next time you breastfeed."
b.) "You should reduce the frequency of breastfeeding."
c.) "Apply expressed breast milk to sore nipples and cover them w/ nursing pads and a bra."
d.) "You should apply warm packs to the breasts between nursing sessions."
a.) "Call me so I can check your baby's latch the next time you breastfeed."
A nurse is assisting with the care of a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect?
a. Urinary output of 40mL/hr
b. Deep abdominal breathing
c. Weak and irregular pulse
d. Warm, dry hands with prompt cap refill
c. Weak and irregular pulse
A nurse is assisting with the care of a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform?
a.) Infuse a 500-mL bolus of 0.9% sodium chloride immediately prior to the procedure
b.) Assess the FHR pattern for 10 min prior to the procedure
c.) Position the client upright and erect on the edge of the bed prior to the procedure
d.) Monitor v/s q15min after the anesthetic is placed
a.) Infuse a 500-mL bolus of 0.9% sodium chloride immediately prior to the procedure
This decreases the risk hypotension.
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make?
a.) "This is an attempt by your body to retain the fluid gained during pregnancy."
b.) "This is caused by an increase in your estrogen hormonal levels."
c.) "This is caused by the increased pressure on your veins in your lower legs."
d.) "This is a source of your fluid loss after delivery."
d.) "This is a source of your fluid loss after delivery."
A nurse is collecting data from a client who is postpartum. The nurse should identify which of the following findings as a manifestation of endometritis?
a. Foul-smelling lochia
b. Fundus 2 cm above the umbilicus
c. Decreased HR
d. Dysuria
a. Foul-smelling lochia
A nurse is reinforcing teaching with a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include?
a.) "Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions."
b.) "You will learn how to prevent pain during labor by focusing your mind to control your breathing."
c.) "During labor, you will be encouraged to disassociate by using an internal focal point."
d.) "During labor, you will use conscious relaxation and levels of progressive breathing."
b.) "You will learn how to prevent pain during labor by focusing your mind to control your breathing."
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make?
a.) "You will not get pregnant while you are breastfeeding, so you will not need any birth control."
b.) "A birth control pill that contains only estrogen is available for use while you are breastfeeding."
c.) "Condoms are the only method of contraception that is appropriate while you are breastfeeding."
d.) "A progestin-only pill or injection is available for use while you are breastfeeding."
d.) "A progestin-only pill or injection is available for use while you are breastfeeding."
Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding.