Maternity - Intrapartum NCLEX question Exam 2

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SAUNDERS MATERNITY: Fetal Distr...

27 terms b_olowogbade Preview Matern 19 terms Jord A nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply.Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Increased uterine resting tone on fetal monitoring

Rationale:

In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa A nurse is developing 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 nursing intervention as the highest priority?

• Monitoring fetal status
• Providing comfort measures
• Changing the client's position frequently
• Keeping the significant other informed of the progress

of the labor

• monitoring fetal status

Rationale:

The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.

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

• Clear and dark amber color
• Light green color with no odor
• Thick white color with no odor
• Straw-colored, with flecks of vernix
• Straw-colored, with fleck of vernix

Rationale:

Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin watery consistency and may have a mild odor. The other options are not descriptions of normal amniotic fluid 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. Which is the initial nursing action?

• Turn the client onto her side and give oxygen by face

mask at 8 to 10 L/min.

• Turn the client onto her back and give oxygen by face

mask at 8 to 10 L/min.

• Turn the client onto her side and give oxygen by nasal

cannula at 2 to 4 L/min.

• Turn the client onto her back and give oxygen by nasal

cannula at 2 to 4 L/min.

• Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.

Rationale:

If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is applied to the mother.The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action?

• Administer oxygen by face mask.
• Clear and maintain an open airway.
• Administer magnesium sulfate intravenously.
• Assess the blood pressure and fetal heart rate.
• Clear and maintain an open airway.

Rationale:

The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow administer oxygen by face mask, administer magnesium sulfate intravenously, asses the blood pressure and fetal heart rate A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment finding would indicate the presence of concealed bleeding?

• Back pain
• Heavy vaginal bleeding
• Increase in fundal height
• Early deceleration on the fetal heart monitor
• Increase in fundal height

Rationale:

The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability.The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia?

• Assessing the mother's reflexes
• Taking the mother's temperature
• Taking the mother's apical pulse
• Monitoring the mother's blood pressure
• Monitoring the mother's blood pressure

Rationale:

A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes.

The 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 beats/minute. Which nursing action is most appropriate?

• Notify the health care provider (HCP).
• Continue monitoring the fetal heart rate.
• Encourage the client to continue pushing with each

contraction.

• Instruct the client's coach to continue to encourage

breathing techniques.

• Notify the health care provider (HCP).

Rationale:

A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified A 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. Which type of labor dystocia should the nurse document that the client is experiencing?

• Hypotonic
• Precipitate
• Hypertonic 4. Preterm labor
• Hypotonic

Rationale:

Hypotonic labor contractions are short, irregular, weak, and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?

• Delivery of the fetus
• Strict monitoring of intake and output
• Complete bed rest for the remainder of the pregnancy
• The need for weekly monitoring o
• Delivery of the fetus

Rationale:

The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Because delivery of the fetus is necessary, the remaining options are incorrect regarding management of the client with abruptio placentae.A nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse should ensure that which is implemented before the beginning of the infusion?

• An IV infusion of antibiotics
• Placing the client on complete bed rest
• Continuous electronic fetal monitoring
• Placing a code cart at the client's bedside
• Continuous electronic fetal monitoring

Rationale:

Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin (Pitocin). There are no data in the question that indicate the need for complete bed rest or the need for antibiotics. It is not necessary to place a code cart at the bedside of a client receiving an oxytocin infusion.The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

• Administer oxygen via face mask.
• Place the mother in a supine position.
• Increase the rate of the oxytocin (Pitocin) intravenous

infusion.

• Document the findings and continue to monitor the

fetal patterns.

• Administer oxygen via face mask.

Rationale:

Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Option 4 would delay necessary treatment

A 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, what is the most appropriate action for the nurse to take?

• Prepare for imminent delivery.
• Continue to monitor the client.
• Report the findings to the obstetrician.
• Report the FHR to the anesthesiologist on call.
• Continue to monitor the client.

Rationale:

The data collected by the nurse are within normal limits and require no further action on the part of the nurse other than continued monitoring. The FHR is normally 120 to 160 beats/min. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute.Which should be the nurse's priority action?

• Reposition the laboring woman to knee-chest.
• Assess the vagina and cervix with a gloved hand.
• Notify the health care provider of the need for an

amnioinfusion.

• Document the description of the fetal bradycardia in

the nursing notes.

• Assess the vagina and cervix with a gloved hand.

Rationale:

It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action would be to glove the examining hand and insert two fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented so therefore option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.A 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 is the initial nursing action?

• Gently push the cord into the vagina.
• Place the client in Trendelenburg's position.
• Find the closest telephone and page the health care

provider stat.

• Call the delivery room to notify the staff that the client

will be transported immediately.

• Place the client in Trendelenburg's position.

Rationale:

When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation.A nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure?

• Assess the fetal heart rate.
• Check the client's temperature.
• Change the pads under the client.
• Check the client's respiratory rate.
• Assess the fetal heart rate.

Rationale:

After amniotomy or rupture of the membranes in the birth setting, the nurse immediately assesses the fetal heart rate for at least 1 minute to detect changes associated with prolapse or compression of the umbilical cord. The quantity, color, and odor of the amniotic fluid also are noted. The client's temperature should be assessed every 2 to 4 hours, and the nurse also would check the client's vital signs. The pads under the client should be changed regularly to promote comfort and reduce the moist environment that favors bacterial growth, but this is not the priority