Question 1

The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which most appropriate nursing actions?

Accepted Answer

Late decelerations can indicate uteroplacental insufficiency, and administering oxygen via face mask can help improve fetal oxygenation.

Question 2

The nurse is assisting the nurse midwife in preparing to perform Leopold's maneuver on a pregnant client. The nurse instructs the client about the procedure and then:

Accepted Answer

Leopold's maneuvers are performed to assess the position and presentation of the fetus. Having the client urinate before the procedure helps ensure comfort and accuracy by reducing bladder interference.

Question 3

A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which of the following findings indicates that the rate of the infusion needs to be decreased?

Accepted Answer

A fetal heart rate of 180 beats/min indicates fetal tachycardia, which can be a sign of fetal distress possibly due to excessive uterine contractions from too much oxytocin.

Question 4

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. The initial nursing action is to:

Accepted Answer

Determining the fetal heart rate is the initial nursing action after the membranes rupture spontaneously to assess for any immediate distress or changes in the fetal condition, ensuring the fetus is not experiencing any complications such as cord prolapse or distress.

Question 5

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:

Accepted Answer

The lengthening of the umbilical cord and a spurt of blood from the vagina are classic signs of placental separation from the uterine wall, indicating that the placenta is ready to be delivered.

Question 6

The nurse is preparing to care for a client in labor. The physician has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which of the following is implemented prior to the beginning of the infusion?

Accepted Answer

Continuous electronic fetal monitoring is essential prior to starting an oxytocin (Pitocin) infusion to assess the fetus's well-being and response to induced contractions, ensuring the safety of both the mother and the fetus during labor induction.

Question 7

The nurse provides a list of discharge instructions to the client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further instructions?

Accepted Answer

Beginning abdominal exercises immediately after a cesarean delivery is not recommended. It's important to allow time for healing before engaging in abdominal exercises. The other options are appropriate post-cesarean care instructions.

Question 8

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse assesses that the amniotic fluid is normal if it has which of the following characteristics?

Accepted Answer

Amniotic fluid is normally straw-colored and may contain flecks of vernix, which are whitish particles from the fetal protective skin layer. This indicates a healthy amniotic environment.

Question 9

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which of the following nursing interventions as the highest priority?

Accepted Answer

Monitoring fetal status is the highest priority in managing dystocia because it directly impacts the well-being of the fetus. Ensuring the fetus is not in distress is critical in guiding further interventions and care decisions.

Question 10

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following findings would alert the nurse to a compromise?

Accepted Answer

The passage of meconium in the amniotic fluid can be a sign of fetal distress or compromise, especially if the fetus has passed meconium while still in utero due to hypoxia or other stressors.

Question 11

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:

Accepted Answer

Pain relief measures are the priority in caring for a client with hypertonic labor because uncoordinated and erratic contractions can be very painful and distressing. Effective pain management can help the client cope better with the labor process.

Question 12

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?

Accepted Answer

Placing the client in Trendelenburg's position (or a position with the pelvis higher than the head) can help relieve pressure on the umbilical cord until medical intervention can be provided, which is critical for maintaining fetal oxygenation.

Question 13

The nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

Accepted Answer

Placenta previa is associated with an increased risk of hemorrhage due to the placenta covering the cervix, which can lead to bleeding during and after delivery.

Question 14

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action would be which of the following?

Accepted Answer

Turning the client on her side helps improve uteroplacental blood flow, reducing the risk of fetal hypoxia. Administering oxygen by face mask at 8 to 10 L/min increases the amount of oxygen available to the fetus, addressing the issue of fetal heart rate slowing and loss of variability.

Question 15

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. The nurse would prepare the client for:

Accepted Answer

Placental abruption, where the placenta detaches from the uterus before childbirth, is a medical emergency that often necessitates the delivery of the fetus to prevent life-threatening complications for both the mother and the baby.

Question 16

The nurse is monitoring a client who is in the active phase 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?

Accepted Answer

Hypotonic labor dystocia occurs when contractions during the active phase of labor are insufficiently strong or frequent to facilitate normal dilation and effacement of the cervix, as described by short, irregular, and weak contractions.

Question 17

The nurse has collected the following data on a client in labor: the fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, the nurse should take which most appropriate action?

Accepted Answer

The fetal heart rate (FHR) of 154 beats/min is within the normal range (110-160 beats/min), and contractions occurring every 5 minutes with a duration of 35 seconds indicate that labor is progressing but not yet in a rapid or concerning phase. Therefore, the most appropriate action is to continue monitoring the client.

Question 18

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client states that her "water broke" before coming to the hospital. The most appropriate nursing action would be to:

Accepted Answer

The most appropriate nursing action when a prolapsed umbilical cord is identified is to wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. This helps to prevent drying and maintain blood flow through the cord until delivery can be accomplished, usually by cesarean section.

Question 19

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the following?

Accepted Answer

The initial nursing action before performing a fundal assessment on a postpartum client is to ask the client to urinate and empty her bladder. This is important because a full bladder can displace the uterus and interfere with an accurate assessment of the uterine position and involution process.

Question 20

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the client's vital signs every:

Accepted Answer

The correct answer is B) 15 minutes during the first hour and then every 30 minutes for the next 2 hours. This protocol is typically followed to closely monitor the mother's vital signs for any signs of complications such as hemorrhage, infection, or hypertension immediately after childbirth.

Quiz 4: Maternity