NCLEX

NCLEX Leave the first rating Students also studied Terms in this set (50) Ecpi UniversityNUR 204 Save intrapartem 51 terms valben6539Preview Intrapartum 82 terms meg_m21Preview intrapartum 100 terms StevenlDavisPreview intrapa 51 terms valb A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms indicate that the client's bleeding is caused by placenta previa? Select all that apply.-Bright red vaginal bleeding -Lack of uterine contractions The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply.-Bright red vaginal bleeding -Soft, relaxed, nontender uterus Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure.Which information should the nurse provide to the client about Leopold's maneuvers?The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?lateral sims The nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which issue?characteristics of contractions The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?fear about what is happening

The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action?determine FHR The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture?shoulder dystocia A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position?Supine with a wedge under the right hip A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply.-Uterus soft to palpation -Bright red vaginal bleeding

At 5:00 am a client is admitted to the maternity unit after

experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions

occurring every 3 minutes. It is now 11:00 am with little

progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action?Prepare the client for a cesarean delivery.A client in preterm labor is placed on bed rest. The nurse assists the client to which advantageous position?Left lateral The nurse is caring for a woman in the labor room. The primary health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?resting interval of 50 secs The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action is to monitor which criteria?All vital signs, especially heart rate and blood pressure A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?Determine the parents' desires for contact with the newborn.The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client.Which nursing intervention should be implemented before this procedure is performed?Have the client empty her bladder.A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?contraction stress test

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares for which appropriate nursing action?Administering oxygen via face mask The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?Decreased periods of uterine relaxation between contractions The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.-The fetus is in the breech position.-Lesions are present on the perineum.-The fetus is not settled into the pelvis.A primigravida's membranes rupture spontaneously.Which action should the nurse take first?Determine the fetal heart rate.The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?newborn Which is the appropriate method to use to deliver the placenta after a precipitate delivery?Gently guide the placenta out after a spontaneous separation.The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal?Prevent dehydration and hypoxemia.The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problem should the nurse expect to note on the plan of care?Anxiety related to a slow progress of labor The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.-Bright red vaginal bleeding -Soft, relaxed, non-tender uterus -Fundal height may be greater than expected for gestational age The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular.Based on these findings, what is the appropriate nursing action?continue to monitor client A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding? Select all that apply.-board like abdomen -Increase in fundal height

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?Supine position with a wedge under the right hip Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which signs as an indication of placental separation? Select all that apply.-Change in uterine shape -Lengthening of the umbilical cord -Sudden gush of dark blood from the introitus The client is informed that she is now in the second stage of labor, the descent phase. Which observations should the nurse make to support this stage of labor? Select all that apply.-Bearing down with contractions -Changing body positions frequently -Making expiratory vocalizations The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?Document the findings and continue to monitor the fetal patterns.The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse should include which in the plan of care?Maintain continuous electronic fetal monitoring.A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?Check the fetal heart rate.A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?"Tell me what you mean when you say that your baby has moved." The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?Baseline fetal heart rate The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor.During admission, which action should the nurse take initially?Determine the maternal and fetal vital signs.A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?The client feels hopeless about the situation.