Maternity Notes for Exam 2, Prepartion
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Questions and Answers

The nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

  • Document the findings and continue to monitor (correct)
  • notify the client's provider
  • increase the frequency of fundal massage
  • encourage the client to empty her bladder
  • A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

  • Stimulate the infant to cry.
  • Clear the respiratory tract. (correct)
  • Cut the umbilical cord.
  • Dry the infant off and cover the head
  • A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min.

  • Position the client with one hip elevated (correct)
  • Ask the client if she needs pain medication
  • Have the client void
  • Notify the provider of the findings.
  • A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn’s plan of care?

    <p>Observe for meconium in respiratory secretions.</p> Signup and view all the answers

    A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

    <p>Insert a gloved hand into the vagina to relieve pressure on the cord.</p> Signup and view all the answers

    A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

    <p>Dyspnea</p> Signup and view all the answers

    A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

    <p>A client who is experiencing preterm labor at 26 weeks of gestation</p> Signup and view all the answers

    A nurse is caring for a client who is postpartum and received methylergonovine (methergine). Which of the following findings indicates that the medication was effective?

    <p>Fundus firm to palpation</p> Signup and view all the answers

    A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

    <p>“The primary consideration is what type of incision was performed this time.&quot;</p> Signup and view all the answers

    A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

    <p>Uteroplacental insufficiency</p> Signup and view all the answers

    A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

    <p>Displaced fundus from the midline</p> Signup and view all the answers

    A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

    <p>Apply perineal pressure to the emerging fetal head</p> Signup and view all the answers

    A nurse is assessing a client who is 12 hr postpartum and receives spinal anesthesia for a cesarean birth.

    <p>Respiratory rate 10/min</p> Signup and view all the answers

    A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg

    <p>Evaluate the firmness of the uterus</p> Signup and view all the answers

    A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

    <p>Poor sucking.</p> Signup and view all the answers

    A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

    <p>Blood pressure 80/56 mm Hg.</p> Signup and view all the answers

    A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect?

    <p>Weakened uterine contractions</p> Signup and view all the answers

    A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

    <p>Obtain a 30 min electronic fetal monitoring (EFM) strip and prepare to give a bolus of Lactated Ringers solution prior to the epidural administration.</p> Signup and view all the answers

    A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse
take first?

    <p>Turn the client onto her side.</p> Signup and view all the answers

    A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

    <p>Apply an ice pack to the affected area.</p> Signup and view all the answers

    A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

    <p>Document fundal height.</p> Signup and view all the answers

    A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

    <p>1.Blot the perineal area dry after cleansing</p> Signup and view all the answers

    A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?

    <p>Encourage the client to empty the bladder every 2 hr</p> Signup and view all the answers

    A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?

    <p>Massage the client's fundus to promote contractions</p> Signup and view all the answers

    A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

    <p>Deep tendon reflexes 4+</p> Signup and view all the answers

    A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statement should indicate to the nurse the teaching is effective? select all the apply

    <p>&quot;I will resume taking my prenatal vitamins.&quot;</p> Signup and view all the answers

    A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

    <p>Breech</p> Signup and view all the answers

    A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

    <p>Check the cervix to determine how close the time of delivery may be prior to analgesic administration.</p> Signup and view all the answers

    A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

    <p>Heart rate 110/min</p> Signup and view all the answers

    A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

    <p>Glyburide</p> Signup and view all the answers

    A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

    <p>Contractions lasting longer than 90 seconds</p> Signup and view all the answers

    A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

    <p>Fundus palpable to right of midline</p> Signup and view all the answers

    A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

    <p>Placental insufficiency</p> Signup and view all the answers

    A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely causes of the respiratory distress is which of the following?

    <p>Hyperinsulinemia</p> Signup and view all the answers

    A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

    <p>Elevate her leg</p> Signup and view all the answers

    A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?

    <p>Preparation for cesarean birth</p> Signup and view all the answers

    A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action?

    <p>Assess the odor of the amniotic fluid.</p> Signup and view all the answers

    A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

    <p>Variable decelerations</p> Signup and view all the answers

    A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

    <p>Continuous contraction lasting 2 min</p> Signup and view all the answers

    A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

    <p>Position the client on her side.</p> Signup and view all the answers

    A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

    <p>Assess the fetal heart rate.</p> Signup and view all the answers

    A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mmHg and the fetal heart rate is 140/min. Which of the followign is the priority nursing action?

    <p>Place the client in a lateral position.</p> Signup and view all the answers

    A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

    <p>Have the client ambulate.</p> Signup and view all the answers

    A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

    <p>Observe for crowning.</p> Signup and view all the answers

    A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

    <p>Hypoglycemia</p> Signup and view all the answers

    A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply).

    <p>Indomethacin</p> Signup and view all the answers

    A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of LR with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include BP 146/95, pulse 80, RR 18. The nurse reviews the prescriptions from the provider. Which of the following prescriptions from the provider. Which of the following prescriptions requires clarification?

    <p>Methylergonovine 0.2 mg IM now</p> Signup and view all the answers

    A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?

    <p>Discontinue the infusion of the IV oxytocin</p> Signup and view all the answers

    A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

    <p>Hypotension</p> Signup and view all the answers

    A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

    <p>Respiratory depression</p> Signup and view all the answers

    A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

    <p>respiratory rate of 16/min</p> Signup and view all the answers

    A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

    <p>client who experienced a cesarean birth 4 hr ago and reports pain</p> Signup and view all the answers

    A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

    <p>&quot;It sounds like you are feeling sad that things didn't go as planned.&quot;</p> Signup and view all the answers

    A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

    <p>Ask the client if she has considered harming her newborn</p> Signup and view all the answers

    a nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precedes the onset of labor. which of the following should the nurse identify as a sign that precede labor?

    <p>a surge of energy</p> Signup and view all the answers

    A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

    <p>&quot;I will reduce my exercise schedule to 3 days a week.&quot;</p> Signup and view all the answers

    A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?

    <p>Pulse Rate or Pulse</p> Signup and view all the answers

    A nurse is caring for a client who experienced a vagina birth 3 hr ago. Upon palpation, the fundus is displaced to the R of the midline, is firm, and is 2 fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

    <p>have the client urinate</p> Signup and view all the answers

    A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated 2 perineal pads with blood in a 30 min period. Which of the following is the priority nursing intervention at this time?

    <p>palpate client uterine fundus</p> Signup and view all the answers

    A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?

    <p>Cervical dilation</p> Signup and view all the answers

    A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

    <p>Document this as an expected finding.</p> Signup and view all the answers

    A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

    <p>Have the client pant during the next contractions.</p> Signup and view all the answers

    A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

    <p>Caput succedaneum</p> Signup and view all the answers

    A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?

    <p>Massage the client's fundus.</p> Signup and view all the answers

    A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

    <p>Uterine atony</p> Signup and view all the answers

    A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

    <p>Assist the client to the bathroom to void.</p> Signup and view all the answers

    A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

    <p>fundus firm, at level of umbilicus</p> Signup and view all the answers

    A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

    <p>A caput succedaneum occurs due to compression of blood vessels.&quot;</p> Signup and view all the answers

    A nurse on the l&d unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

    <p>Dry the newborn's skin thoroughly</p> Signup and view all the answers

    A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority action by the nurse following the procedure?

    <p>Assess the fetal heart rate pattern.</p> Signup and view all the answers

    A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

    <p>Fetal position is persistent occiput posterior.</p> Signup and view all the answers

    A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

    <p>The presenting part is 1cm above the ischial spines.</p> Signup and view all the answers

    A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

    <p>Massage the client's back</p> Signup and view all the answers

    A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. the nurse observes the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?

    <p>Place the client in the lateral position.</p> Signup and view all the answers

    A nurse is caring for a client in the first stage of labor who is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

    <p>Assist the client to breathe into a paper bag.</p> Signup and view all the answers

    A nurse in a prenatal clinic is caring for a client. Using Leopold's maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

    <p>Right upper</p> Signup and view all the answers

    A nurse is caring for a client who is in active labor at 39 weeks of gestation. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

    <p>Frank Breech</p> Signup and view all the answers

    A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?

    <p>Fundus three fingerbreadths above the umbilicus</p> Signup and view all the answers

    A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the clients abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

    <p>at level of umbilicus</p> Signup and view all the answers

    A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

    <p>Variable decelerations are due to umbilical cord compression</p> Signup and view all the answers

    A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

    <p>At the level of the umbilicus</p> Signup and view all the answers

    A nurse is preparing to admin methylergonovine IM to a client who experienced a vaginal deliver. The nurse should explain to the client that the purpose of this med is to prevent which of the following condition?

    <p>postpartum hemorrhage</p> Signup and view all the answers

    A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

    <p>Monitor blood glucose levels.</p> Signup and view all the answers

    A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

    <p>48/min</p> Signup and view all the answers

    A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to

    <p>&quot;You should try to pant as the delivery proceeds.&quot;</p> Signup and view all the answers

    A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

    <p>Respiratory Distress</p> Signup and view all the answers

    A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

    <p>The lowermost portion of the fetus is at the level of the ischial spines</p> Signup and view all the answers

    A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?

    <p>This infection is treated with one dose of azithromycin</p> Signup and view all the answers

    A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?

    <p>&quot;This medication promotes softening of the cervix.&quot;</p> Signup and view all the answers

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