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A laboring client is receiving oxytocin. Which finding requires immediate intervention?
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A nurse is caring for a client in the transition phase of labor. Which behavior is most characteristic of this phase?
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Test Two
| Question | Answer |
|---|---|
| A laboring client is receiving oxytocin. Which finding requires immediate intervention? | Fetal heart rate decelerations with contractions |
| A nurse is caring for a client in the transition phase of labor. Which behavior is most characteristic of this phase? | Increased anxiety and irritability |
| Which intervention is appropriate when caring for a laboring client experiencing hypotension after epidural anesthesia? | Turn to left lateral position |
| Which is the nurse’s priority action when a laboring mother has meconium-stained amniotic fluid? | Notify the neonatal resuscitation team |
| Which is a priority nursing diagnosis for a client in active labor with ruptured membranes? | Risk for infection |
| Which finding is most concerning during labor? | Late decelerations on fetal monitor |
| A nurse notices variable decelerations on the fetal monitor. What should the nurse do first? | Change the mother's position |
| The fetal heart rate shows early decelerations. The nurse should: | Continue to monitor |
| Which is most important to assess immediately after artificial rupture of membranes? | Fetal heart rate |
| Which client is at greatest risk for uterine rupture? | Client with a prior cesarean section |
| A woman at 39 weeks is in early labor. The priority nursing action is to: | Assess fetal heart rate and contraction pattern |
| Which of the following is a presumptive sign of impending labor? | Nesting behavior |
| A woman asks how to recognize true labor. The nurse should explain: | True labor causes cervical change. |
| Which indicates the start of the first stage of labor? | Onset of regular contractions |
| The second stage of labor begins with: | Full cervical dilation (10 cm) |
| The third stage of labor ends with: | Delivery of the placenta |
| The fourth stage of labor involves: | Immediate postpartum recovery |
| A nurse explains that contraction frequency is measured: | From the beginning of one contraction to the beginning of the next |
| Contraction duration is defined as: | Time from the beginning to the end of one contraction |
| Contraction intensity is best assessed by: | Palpating the uterus during contraction |
| Which is a sign of impending labor? | Loss of the mucus plug |
| Which is a characteristic of the transition phase of labor? | Increased irritability and rectal pressure |
| During the second stage, which nursing action is essential? | Encourage pushing with contractions |
| A fetus is in distress. Which maternal condition is likely contributing? | Maternal hypotension |
| The nurse assesses the fetal heart rate immediately after amniotomy. Why? | To check for cord prolapse |
| A woman experiences lightening. What does this mean? | The baby has dropped into the pelvis |
| The bloody show is best described as: | A pink-tinged vaginal discharge from cervical changes |
| The client is in the fourth stage of labor. The nurse should prioritize: | Monitoring for hemorrhage |
| Which maternal sign suggests placental separation? | Fundus becomes firm and rises |
| A client is 4 hours postpartum and complains of severe perineal pain despite medication. What complication does the nurse suspect? | Perineal hematoma |
| What symptom most clearly indicates postpartum depression rather than “baby blues”? | Persistent thoughts of harming the baby |
| A mother reports difficulty urinating 8 hours after delivery. The nurse notes a distended bladder and displaced uterus. What is the priority? | Straight catheterization (in and out cath.) |
| What action should the nurse take first for a woman with signs of postpartum hemorrhage? | Fundal massage |
| Which woman is at highest risk for postpartum hemorrhage? | Multipara with a history of PPH (Postpartum hemorrhage) |
| A postpartum client is diagnosed with a uterine infection. Which medication is expected? | Antibiotics |
| Which factor increases a woman’s risk for postpartum thrombophlebitis? | Cesarean delivery |
| A woman reports severe right breast pain, redness, and warmth. She is breastfeeding. What is the likely diagnosis? | Mastitis |
| A postpartum woman with suspected retained placenta should be assessed for: | Persistent bright red bleeding |
| Which factor is a common cause of postpartum urinary retention? | Epidural anesthesia |
| Which intervention is most effective in preventing postpartum DVT? | Early ambulation |
| A woman has a firm fundus, but heavy bleeding persists. What is the most likely cause? | Vaginal laceration |
| A newborn has a blood glucose level of 35 mg/dL. What is the nurse’s priority action? | Breastfeed immediately |
| Which newborn is at highest risk for hypoglycemia? | Infant of a diabetic mother |
| A newborn presents with poor feeding, jitteriness, and a weak cry. What is suspected? | Hypoglycemia |
| A newborn with meconium-stained fluid at birth is at risk for: | Meconium aspiration syndrome |
| Which newborn should the nurse assess first? | Grunting respirations |
| What is the best prevention for hypothermia in a newborn? | Early skin-to-skin contact |
| A newborn shows signs of respiratory distress. What should the nurse assess first? | Oxygen saturation |
| What finding is most concerning in a newborn at 2 hours old? | Nasal flaring and intercostal retractions |
| Which newborn finding requires immediate follow-up? | Grunting with respirations |
| Which condition places a newborn at highest risk for sepsis? | Prolonged rupture of membranes |
| What are some side effects of an epidural block? | Maternal hypotension and urinary retention |
| What is done immediately after membranes are ruptured? | A Nitrazine test (Fern test) and assess FHR |
| What happens during stage 1, 2, 3, and the 4th stage of labor? | Stage 1: Dilation & Effacement (4-6hrs) Stage 2: Expulsion of fetus (delivery) (30mins-2hrs) Stage 3: Expulsion of Placenta (5-30mins) Stage 4: Recovery (Bonding/skin-to-skin) |
| What are some abnormal newborn assessments? | Hypothermia, hypoglycemia, and respiratory ditress |
| Care of a patient who is having variable decelerations | Position changing, give oxygen, correct hypotension, reduce uterine activity, and push & breathing techniques |
| What are some ways to stimulate contractions? | Oxytocin, methergine, stimulation of the nipples, walking around, and upright sitting |
| Priority when birth is imminent | Prevent injury to mom & baby |
| Normal range of fetal heart rate? | 110-160bpm |
| Define variable, early, and absent deceleration? | Early Deceleration is gradual & temporary drops in FHR during contractions. Variable Deceleration is an abrupt decrease of 15bpm. Absent Deceleration is less than 60bpm. |
| What is late deceleration | It begins after the beginning of the contraction & do not return to normal, meaning reduce blood flow to the placenta & potential fetal acidemia. |
| Definition of frequency of contractions | It's the elapsed time from the beginning of one contraction until the beginning of the next contraction |
| What can a variable deceleration indicate? | Umbilical cord is being compressed, too little amniotic fluid, or fetal respiratory acidosis. |
| Initial care of a newborn at birth | Maintaining thermoregulation, cardiorespiratory function, observing & docu., urination & passage of meconium, identifying mom, partner, & newborn, performing & docu. a brief assessment for major anomalies & encouraging bonding & breastfeeding. |
| When would you not administer pain meds? | If mom is dilated 8-10cm or within 2hrs before delivery |
| Position avoided during labor | Supine (flat on back) |
| Definition of precipitate birth | Completed in less than 3hrs, & no HCP present |
| Definition of relaxation phase of a contraction | When muscles return to its resting state with decrease tension of muscle returning back to its original length |
| What color and amount is abnormal amniotic fluid? | Green color (fetus passed meconium, first stool). Cloudy/yellow means infection. |
| Tx of a third-degree laceration | Cold packs applied to the perineum for the first 12hrs, warmth (heat packs), sitz baths, or administer oral pain meds. |
| How do you know that true labor has begun? | Contractions gradually develop a regular pattern becoming stronger even when walking, lower back/abdomen discomfort, bloody show, & progressive effacement & dilation of cervix |
| Care of a patient with mastitis | Heat, massage the breast, or warm shower |
| Postpartum hemorrhage nursing care | Check vitals, monitor oxygen, assess lochia, massage the fundus, measure I&O, monitor for signs of anemia, & give emotional support |
| Tx of abnormal deceleration | Perform a scalp pH, fetal stimulation, vibroacoustic stimulation, & fetal pulse oximetry to assess urgency for delivery |
| What is the Bishop Score used for? | To assess the ripeness of the cervix for induction, the score needs to be greater than 6. |
| Priority assessment after amniotomy | Assess FHR |
| Why does breastfeeding cause pain in the uterus? | Because when the breast is being stimulated (baby feeding) the oxytocin kicks in & starts the contractions back up. |
| What is the location of the uterus after delivery? | The belly button & will descend 1cm/day |
| Risk factors for Hypoglycemia after birth | Blood glucose less than 45, preterm/posterm, diabetic mom, (LGA) large for gestational age or (SGA), (IUGR) internal uterine growth restriction, asphyxiated, cold stress, or mom had tocolytics during labor |
| What interventions would a nurse do for a mom with a soft "boggy" uterus? | Massage uterus until firm, allow infant to breastfeed, administer a diluted oxytocin IV infusion, methergine, or prostaglandins, & NPO just in case of surgery |
| What is Lochia Rubra, Serosa, & Alba? | Lochia R. is composed of mostly blood about 3days post birth. Lochia S. is pinkish in color mixed with blood & mucus. Lochia A. is mucus clear & colorless or white. |
| Bleeding after delivery what should you do first? | Massage the fundus |
| Priority for care of a newborn after ABC's | Blood sugar & keep infant warm (96.8-97.7) |
| Discharge teaching for a breastfeeding mom? | Drink plenty of fluids, wear a wireless bra, make sure mom is switching to both breasts, take a warm shower, massage breast, or contact lactation consultant |
| Indications for induction of labor | Gestational hypertension, ruptured membranes w/o spontaneous onset of labor, infection within the uterus, med/fetal prob., prolonged preg., incompatibility between mom&baby blood types, placenta insufficiency, & fetal death. |
| What does the nurse do after the MD inserts the epidural? | Observe for low BP, urinary retention, maintain position, check BP q5mins, FHR, catheterization, & ambulation carefully. |
| What are signs of hyperventilation? | SOB, dizziness, & tingling of hands& feet |
| Signs of hypovolemic shock | Increased pulse (tachycardia) |
| What assessment do you need to do before you massage the fundus? | Check for bladder fullness |
| What are contraindications for induction of labor? | Placenta previa, umbilical cord prolapses, abnormal fatal presentation, high station in fetus, active herpes, abnormal pelvis, & previous c-section incision |
| What are complications of NO lochia? | It is not normal needs to be reported, because could mean a blood clot or contained fragments. |
| Postpartum complications to include in postpartum discharge teaching? | Shock, hemorrhage, thromboembolic disorders, puerperal infections, subinvolution of the uterus, & mood disorders |
| What is Homan's Sign? | It's a physical examination to identify DVT (pain in the calf or behind the knee when the foot id dorsiflexed & knee extended) |
| Women w/ varicose veins lead to what after birth? | Prone to blood clots (pulmonary embolism). Watch for tachypnea & dyspnea. |
| What meds. need to be given to a newborn before discharged? | Erythromycin, Vit. K, & Herpes B vaccine dose 1 |
| C-section birth indications | Abnormal labor, inability of the fetus to pass through moms pelvis, maternal conditions (DM), active herpes virus, previous surgery on the uterus, fetal compromise, & placenta previa or abruptio placentae. |
Created by:
chawal