NURS 126 Healthy Labor 5, complete questions & Answers.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the nurse she feels like she needs to have a bowel m ...

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first: a) document the client's relief due to pain medication. b) have naloxone hydrochloride available in the birthing room. c) prepare for birth. d) complete a vaginal examination to determine dilation, effacement, and station. A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include: a) perform sterile vaginal examination, increase IV fluids, and apply oxygen. b) notify the provider, explain findings to the client, and begin pushing. c) reposition the client, apply oxygen, and increase IV fluids. d) prepare for birth, reposition the patient, and begin pushing. A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for: a) diaphoresis. b) headache. c) tremors. d) hypotension. A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client’s chart (shown below), into which of the following positions would the nurse assist the client—late decal pic a) Supine b) Right lateral c) Prone d) Left lateral A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered? a) The uterus changes to discoid shape. b) The cord lengthens outside the vagina. c) The uterus cannot be palpated. d) There is decreased vaginal bleeding The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time? a) lying in the left lateral recumbent position b) walking around in the hallway c) resting in the right lateral recumbent position d) sitting in a comfortable chair for a period of time A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby is coming!" To help the client remain calm and cooperative during the imminent birth, which response by the nurse is most appropriate? a) "You are right, the baby is coming, so just relax." b) "Please do not push because you will tear your cervix." c) "Your health care provider will be here as soon as possible." d) "I will explain what is happening to guide you as we go along." A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse understands that which condition is a contraindication to hydrotherapy? a) ruptured membranes b) diabetes mellitus c) multifetal gestation d) hypotonic labor patterns During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? a) Contractions will be stronger and more uncomfortable and will peak more abruptly. b) Contractions will be stronger and shorter and will peak more slowly. c) Contractions will be weaker, longer, and more effective. d) Contractions will be stronger, shorter, and less uncomfortable. The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? a) umbilical cord b) chest c) head d) placenta While a 31-year-old multigravida at 39 weeks’ gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client’s cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first? a) Prepare the client for imminent birth. b) Auscultate the client's blood pressure. c) Perform a vaginal examination to determine dilation. d) Note the color, amount, and odor of the amniotic fluid. A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which finding would indicate fetal hypoxia? a) Excessive fetal activity and fetal tachycardia b) Excessively frequent contractions, with rapid fetal movement c) Abnormally strong uterine contractions d) Abnormally long uterine contractions The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding? a) contractions 3 minutes apart and lasting 40 seconds b) sleeping after administration of IV nalbuphine c) an episode of nausea after administration of an epidural anesthetic d) evidence of spontaneous rupture of the membranes A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective? a) back b) abdomen c) perineum d) fundus The multigravid client with a history of rapid labor who is in active labor calls out to the nurse, “The baby is coming!” What should be the nurse’s first action? a) Inspect the perineum. b) Auscultate the fetal heart rate. c) Time the contractions. d) Contact the health care provider. The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which action should the nurse do next? a) Apply gentle upward traction on the neonate's anterior shoulder. b) Tell the client to push between contractions. c) Massage the perineum to stretch the perineal tissues. d) Provide gentle support to the fetal head. The nurse is managing care of a primigrada at full term who is in active labor. What should be included in developing the plan of care for this client? a) supine positioning on back, if it is comfortable b) vaginal bleeding, rupture of membrane assessment every shift c) oxygen saturation monitoring every half hour d) anesthesia/pain level assessment every 30 minutes The nurse is caring for a multigravida in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. The nurse should: a) administer oxygen by mask at 8 L. b) ask the client to push in the squatting position. c) continue to monitor the client and fetus. d) turn the client to her left side. Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client is irritable and has had some nausea with one episode of vomiting. The client is most likely experiencing: a) spontaneous rupture of the membranes. b) a precipitous labor pattern. c) fear and anxiety related to the labor outcome. d) transition phase of labor. A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? a) Ensure adequate hydration before the anesthetic is administered. b) Administer ephedrine to raise her blood pressure. c) Administer oxygen using a mask. d) Place the woman supine with her legs raised. pregnant client’s labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which suggestion would be most helpful for the client’s partner? a) “Keep a record of her contraction pattern." b) “Have her practice rapid, shallow breathing." c) “Suggest that she receive an epidural anesthetic." d) “Encourage her to rest between contractions." While waiting for the placenta to deliver, the nurse should not take any action before: a) observing for signs of placental separation. b) asking the client to push down forcefully. c) massaging the fundus firmly. d) reaching into the uterus with sterile gloves Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first: a) assess the client's cervical dilation and station. b) warm the temperature of the room by a few degrees. c) obtain an order for an intramuscular antiemetic medication. d) increase the rate of intravenous fluid administration. What should be the nurse’s priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? a) cognitive function b) level of consciousness c) contraction pattern d) blood pressure A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. The expected outcome of this drug is: a) the cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position. b) contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. c) contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg. d) the cervix will begin to dilate 2 cm/h. In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring (EFM) in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion? a) Late decelerations b) Fetal heart rate accelerations c) Persistent fetal bradycardia d) Variable decelerations A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem? a) hyperventilation b) pain c) urinary retention d) ineffective coping Which fetal presentation is most favorable for birth? a) Posterior position of the fetal head b) Vertex presentation c) Frank breech presentation d) Transverse lie The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess: a) status of membranes. b) fetal heart rate variability. c) bladder status. d) cervical dilation again. After teaching a woman who is in labor about the purpose of the episiotomy, which purpose stated by the client would indicate to the nurse that the teaching was effective? a) ensures quick placental delivery b) enlarges the pelvic inlet c) prevents perineal edema d) assists with birth of a large baby The nurse is assisting with birth to a multigravida in active labor who is not having anesthesia. The, client's cervix is completely dilated. The nurse should assist the the client to deliver the fetal head by pushing: a) near the end of a contraction. b) as soon as a contraction begins. c) when she has an urge to push. d) between contractions. A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which assessment would be most important? a) maternal pulse b) level of consciousness c) level of anesthesia d) fetal heart rate The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, “Help me, help me!” Her last vaginal exam 1 hour ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client? a) Palpate the bladder to see if it has become distended. b) Ask the client for suggestions to make her more comfortable. c) Help the client through contractions until a narcotic can be given. d) Perform a vaginal examination to determine if the client is fully dilated. A client in labor asks the nurse about Reiki, an alternative therapy that she's heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of: a) energy from a light source. b) mind-body control. c) energy from light touch. d) vigorous massage. The nurse is caring for a client in labor who is receiving epidural anesthesia. The nurse assesses a blood pressure of 80/40 mm Hg. Which of the following interventions will the nurse include in the client’s plan of care? a) Turn off the client’s epidural infusion b) Increase the epidural infusion rate c) Increase the client’s fluid rate d) Monitor the fetal heart rate Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V. administration of oxytocin. Why must the nurse monitor the client's fluid intake and output closely during oxytocin administration? a) Oxytocin causes excessive thirst. b) Oxytocin is toxic to the kidneys. c) Oxytocin causes water intoxication. d) Oxytocin has a diuretic effect. The nurse is caring for a client in labor who has requested epidural anesthesia. Which of the following will the nurse include in the client’s plan of care? Select all that apply. a) Continuous external fetal heart monitoring b) Application of oximetry during insertion of epidural anesthesia c) Maintain client in a Fowler's position after epidural insertion d) Monitoring blood pressure every 4 hours e) Infusion of fluid bolus prior to epidural anesthesia A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next? a) Use the McDonald procedure to widen the pelvic opening. b) Increase the rate of oxygen and intravenous fluids. c) Tell the client to push only when absolutely necessary. d) Instruct the client to use a pant-blow pattern of breathing. The primigravid client is at +1 station and 9 cm dilated. Based on these data, the nurse should first: a) assist the client to push if she feels the need to do so. b) ask the anesthesiologist to increase epidural rate. c) support family members in providing comfort measures. d) encourage the client to breathe through the urge to push.