Question 1

The nurse is caring for a client receiving oxytocin for induction of labor and notes that the client's contraction pattern shows a duration of 100 seconds and a frequency of 90 seconds.Which is the nurse's next action at this time?

Accepted Answer

Stopping the oxytocin is necessary because the contraction pattern indicates hyperstimulation of the uterus, which can be harmful to both the mother and the baby. Contraction duration over 90 seconds and frequency less than 2 minutes apart can reduce fetal oxygen supply and uterine blood flow.

Question 2

The nurse is admitting a client at full term to the labor and delivery unit.Using Leopold's maneuvers,the nurse determines that the fetus is in the left sacroanterior position (LSA)position and will obtain the fetal heart rate (FHR)at which site on the client's abdomen?

Accepted Answer

B

Question 3

The nurse assesses the fundus of a client who delivered 6 hours ago and notes that it is 2 centimeters above the umbilicus and is displaced to the right.Which is the nurse's best action at this time?

Accepted Answer

The fundus being 2 centimeters above the umbilicus and displaced to the right suggests that the bladder may be full, which can displace the uterus. Asking the client to void can help in repositioning the uterus to its expected position post-delivery.

Question 4

The nurse has completed applying the ultrasound transducer to the client's abdomen and has confirmed that the rate is not the same as the client's.Which other assessment will assist the nurse in confirming that the sound that is heard is the true fetal heart rate (FHR)?

Accepted Answer

The answer of The nurse has completed applying the ultrasound...

Question 5

The nurse is admitting a client to the labor and delivery unit who states she is at 39 weeks and began having steady contractions approximately 6 hours ago.Which assessment findings discovered during the nurse's vaginal examination would indicate that this client will deliver within the next few hours? Select all that apply.

Accepted Answer

A) Cervical dilation of 7 centimeters indicates that the client is in active labor and progressing towards delivery. Active labor is typically characterized by dilation from 6 to 10 centimeters, and it is during this phase that labor progresses more rapidly towards delivery.D) Ruptured membranes (water breaking) suggest that labor is progressing and delivery could be imminent. Once the membranes have ruptured, there is an increased risk of infection, so delivery within a reasonable timeframe is desirable.E) The presence of a bloody show is a sign that labor is progressing. It occurs as the cervix dilates and effaces, causing small blood vessels to break. This is a common sign that labor is advancing and delivery may happen soon.

Question 6

The nurse is using a Doppler for obtaining the fetal heart tone of a client who is at 28 weeks gestation and obtains a rate of 98 bpm.Which is the nurse's next action for this client?

Accepted Answer

The nurse should first take the client's pulse to ensure that the Doppler is not picking up the maternal heart rate instead of the fetal heart rate, which should be higher than 98 bpm at 28 weeks gestation.

Question 7

The nurse is caring for a woman who has been diagnosed with preeclampsia and has been placed on intravenous magnesium sulfate to prevent seizures.After checking the patellar deep tendon reflex,the nurse documents the response as 2+.Which is the nurse's next action after this assessment?

Accepted Answer

The answer of The nurse is caring for a woman...

Question 8

A 16-year-old client comes to the prenatal clinic and is very concerned about a black line that has appeared on her abdomen.Which statement by the nurse will be most helpful to this client concerning this issue?

Accepted Answer

The linea nigra is a common and normal change during pregnancy due to hormonal changes, specifically increased melanin production.

Question 9

The nurse is caring for a client who is prescribed to have labor induced with oxytocin.Which assessments must be completed by the nurse before initiating the oxytocin infusion? Select all that apply.

Accepted Answer

Before initiating an oxytocin infusion for labor induction, it is essential to assess the fetal heart rate to ensure fetal well-being, determine the client's hydration status to prevent complications related to fluid balance, and apply the tocodynamometer to monitor uterine activity and contractions. These assessments help ensure both maternal and fetal safety during labor induction.

Question 10

The nurse is assisting the health care provider with the first prenatal exam of a client.Prior to the vaginal speculum examination,which information should the nurse give the client to improve the client's comfort during the examination?

Accepted Answer

Bearing down as the speculum is being inserted can help relax the pelvic muscles, making the insertion process more comfortable for the client.

Question 11

The nurse receives a call from a primapara who is at 37 weeks gestation.The client states,"I just wanted to let you know that we are on our way to the hospital.All of a sudden,my belly dropped so I know that I will be delivering the baby very soon." Which is the nurse's best response to this client?

Accepted Answer

The dropping of the belly, also known as lightening, is a sign that the baby is getting into position for birth by moving into the pelvis. However, it does not necessarily mean that labor will start immediately. It's a preparation stage, and labor could still be days or weeks away. Therefore, the nurse's response that acknowledges the client's experience and offers an evaluation without causing alarm is most appropriate.

Question 12

The certified nurse-midwife (CNM)is doing the first prenatal assessment on a client who states she believes she is 6 weeks pregnant.Which assessment finding by the CNM would indicate that this is the correct gestational age?

Accepted Answer

Chadwick's sign, which is the bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow, can be observed as early as 6 to 8 weeks of pregnancy. This makes it a reliable early sign of pregnancy, indicating that the client's belief of being 6 weeks pregnant could be correct. The other options are not typically associated with a pregnancy of 6 weeks.

Question 13

The nurse is caring for a client who is 6 cm dilated with a fetus who has been diagnosed with a serious congenital heart defect.The client has rejected the use of continuous fetal monitoring so the nurse will use the Doppler and monitor the fetal heart rate (FHR)at what frequency?

Accepted Answer

In cases where continuous fetal monitoring is rejected, intermittent monitoring using a Doppler is recommended. For a client in active labor (4-7 cm dilated), the American College of Obstetricians and Gynecologists (ACOG) recommends assessing the fetal heart rate every 15-30 minutes. Given the fetus's serious congenital heart defect, more frequent monitoring (every 15 minutes) is prudent to promptly identify any distress or changes in the fetal condition.

Question 14

The nurse is assessing a client who is 36 weeks pregnant.Her current pulse is 101 bpm,which represents an increase of 10 bpm since her first assessment at 9 weeks of gestation.Which is the nurse's best action related to this assessment finding?

Accepted Answer

BDuring pregnancy, a slight increase in heart rate is normal due to the increased blood volume and cardiac output needed to support the growing fetus. A rise of 10 bpm from the first assessment to 36 weeks can be within normal limits, hence documenting the finding is appropriate (A). Retaking the pulse after a short period of rest (B) is also a prudent action to ensure the increase is not due to temporary factors like activity or anxiety. Reporting to the healthcare provider immediately (D) may not be necessary for this level of increase unless accompanied by other concerning symptoms. Teaching the client to monitor her pulse regularly (C) might not be indicated based solely on this information.

Question 15

The nurse is admitting a client to the labor and delivery unit and is preparing to apply the tocodynamometer (toco).Which must the nurse do first to properly apply this equipment?

Accepted Answer

Locating the uterine fundus is the first step in properly applying a tocodynamometer because it helps in accurately positioning the device to monitor uterine contractions.

Question 16

The nurse is performing the first Leopold maneuver on a client of 34 weeks gestation and notes the presence of fetal bottom and legs.The nurse knows that this maneuver would indicate which for this client?

Accepted Answer

The first Leopold maneuver involves palpating the upper part of the uterus to identify the fetal part present at the fundus. If the nurse feels the fetal bottom and legs, it indicates that the fetus is in a breech position, where the baby's buttocks or feet are positioned to come out first during delivery. This often necessitates a caesarean section for birth, as vaginal delivery can be more complicated or risky in breech presentations.

Question 17

The nurse is caring for a client who is in active labor and has just had an amniotomy.The nurse notes that the fetal heart rate has decreased from 140 bpm immediately prior to the amniotomy to 95 bpm.Upon vaginal examination,the nurse feels a portion of the umbilical cord in the vagina.Which is the nurse's next action in caring for this client?

Accepted Answer

C) Assisting the client to the knee-chest position and notifying the healthcare provider is the correct action. This position helps relieve pressure on the umbilical cord, potentially improving fetal oxygenation and circulation until further medical intervention can be provided.

Question 18

The nurse is discussing anticipated weight gain with a client who has a BMI of 32.Which statement by the client indicates understanding of the topic?

Accepted Answer

Clients with a higher BMI (overweight or obese) are often advised to limit their weight gain during pregnancy to ensure both their health and the health of the baby. The recommendation for weight gain varies based on pre-pregnancy BMI, and for those with a BMI of 30 or higher, the recommendation is usually to gain between 11 and 20 pounds. This approach helps manage the risk of gestational diabetes, hypertension, and complications during delivery.

Question 19

The nurse is assessing a pregnant client who is at 29 weeks gestation.The nurse notes that the client's blood pressure is 160/90 and documents that the clonus was noted after assessing the patellar reflex.Which assessment findings led the nurse to document this finding?

Accepted Answer

Clonus is a series of involuntary, rhythmic, muscular contractions and relaxations. It is often triggered by a sudden stretch of the muscle, in this case, induced by dorsiflexing the foot. The tapping of the client's foot against the nurse's hand indicates these involuntary contractions, which is why the nurse documented clonus.

Question 20

The nurse is caring for a client at 33 weeks gestation who is being monitored for possible preeclampsia.The nurse prepares to check the client's patellar deep tendon reflex and places the client in which position?

Accepted Answer

The answer of The nurse is caring for a client...

Quiz 14: Reproduction