Question

Question 1

A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted?

A

The client begins to expel clear vaginal fluid

B

The contractions are regular

C

The membranes have ruptured

D

The cervix is dilated completely

Question 2

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to:

A

Place the mother in the supine position

B

Document the findings and continue to monitor the fetal patterns

C

Administer oxygen via face mask

D

Increase the rate of pitocin IV infusion

Question 3

A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician?

A

Fetal heart rate of 180 beats per minute

B

White blood cell count of 12,000

C

Maternal pulse rate of 85 beats per minute

D

Hemoglobin of 11.0 g/dL

Question 4

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the:

A

Trendelenburg’s position with the legs in stirrups

B

Semi-Fowler position with a pillow under the knees

C

Prone position with the legs separated and elevated

D

Supine position with a wedge under the right hip

Question 5

A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:

A

Noting if the heart rate is greater than 140 BPM

B

Placing the diaphragm of the Doppler on the mother abdomen

C

Performing Leopold’s maneuvers first to determine the location of the fetal heart

D

Palpating the maternal radial pulse while listening to the fetal heart rate

Question 6

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

A

Three contractions occurring within a 10-minute period

B

A fetal heart rate of 90 beats per minute

C

Adequate resting tone of the uterus palpated between contractions

D

Increased urinary output

Question 7

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion?

A

Placing the client on complete bed rest

B

Continuous electronic fetal monitoring

C

An IV infusion of antibiotics

D

Placing a code cart at the client’s bedside

Question 8

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate?

A

Encourage the client’s coach to continue to encourage breathing exercises

B

Encourage the client to continue pushing with each contraction

C

Continue monitoring the fetal heart rate

D

Notify the physician or nurse midwife

Question 9

A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate?

A

Document the findings and tell the mother that the monitor indicates fetal well-being

B

Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen

C

Notify the physician or nurse midwife of the findings

D

Reposition the mother and check the monitor for changes in the fetal tracing

Question 10

A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client’s abdomen. After attachment of the monitor, the initial nursing assessment is which of the following?

A

Identifying the types of accelerations

B

Assessing the baseline fetal heart rate

C

Determining the frequency of the contractions

D

Determining the intensity of the contractions

Question 11

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is:

A

1 cm above the ischial spine

B

1 fingerbreadth below the symphysis pubis

C

1 inch below the coccyx

D

1 inch below the iliac crest

Question 12

A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client’s hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following?

A

A loud mouth

B

Low self-esteem

C

Hemorrhage

D

Postpartum infections

Question 13

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

A

Hematoma

B

Placenta previa

C

Uterine atony

D

Placental separation

Question 14

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have:

A

Less pressure on her cervix

B

Increased efficiency of contractions

C

Decreased number of contractions

D

The need for increased maternal blood pressure monitoring

Question 15

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?

A

Early decelerations

B

Variable decelerations

C

Late decelerations

D

Short-term variability

Question 16

A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is:

A

A form of biofeedback to enhance bearing down efforts during delivery

B

Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus

C

The application of pressure to the sacrum to relieve a backache

D

Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

Question 17

A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as:

A

Exhaustion

B

Fear of losing control

C

Involuntary grunting

D

Valsalva’s maneuver

Question 18

A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. 1. Stop of Pitocin infusion 2. Perform a vaginal examination 3. Reposition the client 4. Check the client’s blood pressure and heart rate 5. Administer oxygen by face mask at 8 to 10 L/min

A

1, 2, 3, 4, 5

B

1, 4, 2, 3, 5

C

1, 4, 3, 5, 2

D

1, 2, 4, 5, 3

Question 19

A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician’s orders and would expect to note which of the following prescribed treatments for this condition?

A

Medication that will provide sedation

B

Increased hydration

C

Oxytocin (Pitocin) infusion

D

Administration of a tocolytic medication

Question 20WRONG

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

A

Monitor the Pitocin infusion closely

Provide pain relief measures

C

Prepare the client for an amniotomy

Promote ambulation every 30 minutes

Question 20 Explanation:

Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.

Question 21

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

A

Keeping the significant other informed of the progress of the labor

B

Providing comfort measures

C

Monitoring fetal heart rate

D

Changing the client’s position frequently

Question 22

A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor:

A

Over the fetus that is most anterior to the mother’s abdomen

B

Over the fetus that is most posterior to the mother’s abdomen

C

So that each fetal heart rate is monitored separately

D

So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

Question 23

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with 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?

A

Disseminated intravascular coagulation

B

Chronic hypertension

C

Infection

D

Hemorrhage

Question 24

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?

A

The umbilical cord shortens in length and changes in color

B

A soft and boggy uterus

C

Maternal complaints of severe uterine cramping

D

Changes in the shape of the uterus

Question 25

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the fanny. Which of the following would be the initial nursing action?

A

Place the client in Trendelenburg’s position

B

Call the delivery room to notify the staff that the client will be transported immediately

C

Gently push the cord into the fanny

D

Find the closest telephone and stat page the physician

Question 26

A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?

A

Swelling of the calf in one leg

B

Prolonged clotting times

C

Decreased platelet count

D

Petechiae, oozing from injection sites, and hematuria

Question 27

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

A

Absence of abdominal pain

B

A soft abdomen

C

Uterine tenderness/pain

D

Painless, bright red vaginal bleeding

Question 28

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician’s orders and would question which order?

A

Prepare the client for an ultrasound

B

Obtain equipment for external electronic fetal heart monitoring

C

Obtain equipment for a manual pelvic examination

D

Prepare to draw a Hgb and Hct blood sample

Question 29

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for:

A

Complete bed rest for the remainder of the pregnancy

B

Delivery of the fetus

C

Strict monitoring of intake and output

D

The need for weekly monitoring of coagulation studies until the time of delivery

Question 30

A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred?

A

Hypotonic contractions

B

Forceps delivery

C

Schultz delivery

D

Weak bearing down efforts

NO PHOTO PLEASE THANKS

Answer 1

1.D The cervix is dilated completely
The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.
2.C Administer oxygen via face mask

Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary.
3.A Fetal heart rate of 180 beats per minute normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification
4.
D
Supine position with a wedge under the right hip Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus
5.D
The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates
.6.B
7.B
Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.
8.D
A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified
9.A
Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.
10.B
Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur.

Options 1 and 3 are important to assess, but not as the first priority.
11.A
12.C.
13.D
14.B
15.B Variable decelerations
16.B
17.B
18.B 1, 4, 2, 3, 5
19.C
20.B
21.C
22.C
23.D
24.D
25.A
26.A
27.C
28.C
29.B
30.B