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11/15/21, 12:31 AM

Intrapartu

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Intrapartum NCLEX questions Terms in this set (41) 1.A nurse is caring for a client in

1.4. The second stage of labor begins when the

labor. The nurse determines

cervix is dilated completely and ends with the birth

that the client is beginning in

of the neonate.

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

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phases of labor. The nurse is

and oxygen to the fetus during the uterine

assessing the fetal patterns and

contractions. This causes hypoxemia; therefore

notes a late deceleration on

oxygen is necessary. The supine position is avoided

the monitor strip. The most

because it decreases uterine blood flow to the

appropriate nursing action is

fetus. The client should be turned to her side to

to:

displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is

1.Place the mother in the

discontinued when a late deceleration is noted.

supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion

A nurse is performing an

1. A normal fetal heart rate is 120-160 beats per

assessment of a client who is

minute. A count of 180 beats per minute could

scheduled for a cesarean

indicate fetal distress and would warrant physician

delivery. Which assessment

notification. By full term, a normal maternal

finding would indicate a need

hemoglobin range is 11-13 g/dL as a result of the

to contact the physician?

hemodilution caused by an increase in plasma volume during pregnancy.

1.Fetal heart rate of 180 beats per minute 2.White blood cell count of 12,000 3.Maternal pulse rate of 85 beats per minute 4.Hemoglobin of 11.0 g/dL

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prepared for a cesarean

lower trunk and extremities. This leads to decreasing

delivery. The client is

cardiac return, cardiac output, and blood flow to

transferred to the delivery

the uterus and the fetus. The best position to

room table, and the nurse

prevent this would be side-lying with the uterus

places the client in the:

displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position;

1.Trendelenburg's position with

however, a wedge placed under the right hip

the legs in stirrups

provides displacement of the uterus.

2.Semi-Fowler position with a pillow under the knees 3.Prone position with the legs separated and elevated 4.Supine position with a wedge under the right hip

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auscultate the fetal heart rate

fetal heart rate to differentiate the two. If the fetal

by using a Doppler ultrasound

and maternal heart rates are similar, the nurse may

device. The nurse most

mistake the maternal heart rate for the fetal heart

accurately determines that the

rate. Leopold's maneuvers may help the examiner

fetal heart sounds are heard

locate the position of the fetus but will not ensure a

by:

distinction between the two rates.

1.Noting if the heart rate is greater than 140 BPM 2.Placing the diaphragm of the Doppler on the mother abdomen 3.Performing Leopold's maneuvers first to determine the location of the fetal heart 4.Palpating the maternal radial pulse while listening to the fetal heart rate

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by IV infusion to stimulate

indicate fetal distress and the need to discontinue to

uterine contractions. Which

pitocin. The goal of labor augmentation is to

assessment finding would

achieve three good-quality contractions in a 10-

indicate to the nurse that the

minute period.

infusion needs to be discontinued? 1.Three contractions occurring within a 10-minute period 2.A fetal heart rate of 90 beats per minute 3.Adequate resting tone of the uterus palpated between contractions 4.Increased urinary output

A nurse is beginning to care for

2. Continuous electronic fetal monitoring should be

a client in labor. The physician

implemented during an IV infusion of Pitocin.

has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? 1.Placing the client on complete bed rest 2.Continuous electronic fetal monitoring 3.An IV infusion of antibiotics 4.Placing a code cart at the client's bedside

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client is having contractions

indicate the need for immediate medical

every 3 minutes that last 45

management, and the physician or nurse mid-wife

seconds. The nurse notes that

needs to be notified.

the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? 1.Encourage the client's coach to continue to encourage breathing exercises 2.Encourage the client to continue pushing with each contraction 3.Continue monitoring the fetal heart rate 4.Notify the physician or nurse mid-wife

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fetal heart rate patterns. The

caused by fetal movement. Episodic accelerations

nurse notes the presence of

are thought to be a sign of fetal-well being and

episodic accelerations on the

adequate oxygen reserve.

electronic fetal monitor tracing. Which of the following actions is most appropriate? 1.Document the findings and tell the mother that the monitor indicates fetal well-being 2.Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. 3.Notify the physician or nurse mid-wife of the findings. 4.Reposition the mother and check the monitor for changes in the fetal tracing

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Intrapartum NCLEX questions attaches an external electronic

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baseline rate will be identified if they occur.

fetal monitor to the client's abdomen. After attachment of

Options 1 and 3 are important to assess, but not as

the monitor, the initial nursing

the first priority.

assessment is which of the following? 1.Identifying the types of accelerations 2.Assessing the baseline fetal heart rate 3.Determining the frequency of the contractions 4.Determining the intensity of the contractions

A nurse is reviewing the record

1. Station is the relationship of the presenting part to

of a client in the labor room

an imaginary line drawn between the ischial spines,

and notes that the nurse

is measured in centimeters, and is noted as a

midwife has documented that

negative number above the line and a positive

the fetus is at -1 station. The

number below the line. At -1 station, the fetal

nurse determines that the fetal

presenting part is 1 cm above the ischial spines.

presenting part is: 1.1 cm above the ischial spine 2.1 fingerbreadth below the symphysis pubis 3.1 inch below the coccyx 4.1 inch below the iliac crest

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is performed, and the nurse

infection, and poor wound healing. Anemia does

notes that the client's

not specifically present a risk for hemorrhage.

hemoglobin and hematocrit

Having a loud mouth is only related to the person

levels are low, indicating

typing up this test.

anemia. The nurse determines that the client is at risk for which of the following? 1.A loud mouth 2.Low self-esteem 3.Hemorrhage 4.Postpartum infections

A nurse assists in the vaginal

4. As the placenta separates, it settles downward

delivery of a newborn infant.

into the lower uterine segment. The umbilical cord

After the delivery, the nurse

lengthens, and a sudden trickle or spurt of blood

observes the umbilical cord

appears.

lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: 1.Hematoma 2.Placenta previa 3.Uterine atony 4.Placental separation

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membranes are still intact, and

augment labor if the process begins to slow.

the nurse-midwife prepares to

Rupturing of membranes allows the fetal head to

perform an amniotomy. A nurse

contact the cervix more directly and may increase

who is assisting the nurse-

the efficiency of contractions.

midwife explains to the client that after this procedure, she will most likely have: 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased maternal blood pressure monitoring

A nurse is monitoring a client in

2. Variable decelerations occur if the umbilical cord

labor. The nurse suspects

becomes compressed, thus reducing blood flow

umbilical cord compression if

between the placenta and the fetus. Early

which of the following is noted

decelerations result from pressure on the fetal head

on the external monitor tracing

during a contraction. Late decelerations are an

during a contraction?

ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction.

1.Early decelerations

Short-term variability refers to the beat-to-beat

2.Variable decelerations

range in the fetal heart rate.

3.Late decelerations 4.Short-term variability

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labor. The nurse tells the client

and is used before transition to promote relaxation

that effleurage is:

and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.

1.A form of biofeedback to enhance bearing down efforts during delivery 2.Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus 3.The application of pressure to the sacrum to relieve a backache 4.Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

A nurse is caring for a client in

2. Pains, helplessness, panicking, and fear of losing

the second stage of labor. The

control are possible behaviors in the 2nd stage of

client is experiencing uterine

labor.

contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: 1.Exhaustion 2.Fear of losing control 3.Involuntary grunting 4.Valsalva's maneuver

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and notes that the client is

If uterine hypertonicity occurs, the nurse

experiencing hypertonic

immediately would intervene to reduce uterine

uterine contractions. List in

activity and increase fetal oxygenation. The nurse

order of priority the actions

would stop the Pitocin infusion and increase the

that the nurse takes.

rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a

1.Stop of Pitocin infusion

side-lying position, and administer oxygen by snug

2.Perform a vaginal

face mask at 8-10 L/min. The nurse then would

examination

attempt to determine the cause of the uterine

3.Reposition the client

hypertonicity and perform a vaginal exam to check

4.Check the client's blood

for prolapsed cord

pressure and heart rate 5.Administer oxygen by face mask at 8 to 10 L/min

A nurse is assigned to care for

3. Therapeutic management for hypotonic uterine

a client with hypotonic uterine

dysfunction includes oxytocin augmentation and

dysfunction and signs of a

amniotomy to stimulate a labor that slows.

slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? 1.Medication that will provide sedation 2.Increased hydration 3.Oxytocin (Pitocin) infusion 4.Administration of a tocolytic medication

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promote a normal labor pattern.

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: 1.Monitor the Pitocin infusion closely 2.Provide pain relief measures 3.Prepare the client for an amniotomy 4.Promote ambulation every 30 minutes

A nurse is developing a plan of

3. The priority is to monitor the fetal heart rate.

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? 1.Keeping the significant other informed of the progress of the labor 2.Providing comfort measures 3.Monitoring fetal heart rate 4.Changing the client's position frequently h

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labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: 1.Over the fetus that is most anterior to the mothers abdomen 2.Over the fetus that is most posterior to the mothers abdomen 3.So that each fetal heart rate is monitored separately 4.So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

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just delivered a newborn infant

intertwining musculature as the fundus of the uterus,

following a pregnancy with

this site is more prone to bleeding.

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? 1.Disseminated intravascular coagulation 2.Chronic hypertension 3.Infection 4.Hemorrhage

A nurse in the delivery room is

4. Signs of placental separation include lengthening

assisting with the delivery of a

of the umbilical cord, a sudden gush of dark blood

newborn infant. After the

from the introitus (vagina), a firmly contracted

delivery of the newborn, the

uterus, and the uterus changing from a discoid (like

nurse assists in delivering the

a disk) to a globular (like a globe) shape. The client

placenta. Which observation

may experience vaginal fullness, but not severe

would indicate that the

uterine cramping. I am going to look more into this

placenta has separated from

answer. According to our book on page 584, this is

the uterine wall and is ready

not one of our options.

for delivery? 1.The umbilical cord shortens in length and changes in color 2.A soft and boggy uterus 3.Maternal complaints of severe uterine cramping 4.Changes in the shape of the uterus

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assessment on a pregnant

fetal oxygenation. The mother should be positioned

client in labor. The nurse notes

with the hips higher than the head to shift the fetal

the presence of the umbilical

presenting part toward the diaphragm. The nurse

cord protruding from the

should push the call light to summon help, and

vagina. Which of the following

other staff members should call the physician and

would be the initial nursing

notify the delivery room. No attempt should be

action?

made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold

1.Place the client in

the presenting part off of the umbilical cord.

Trendelenburg's position

Oxygen at 8 to 10 L/min by face mask is delivered to

2.Call the delivery room to

the mother to increase fetal oxygenation.

notify the staff that the client will be transported immediately 3.Gently push the cord into the vagin...