■ The Multigravid Client in Labor
■ The Labor Experience
■ The Intrapartal Client with Risk Factors
■ Managing Care Quality and Safety
■ Answers, Rationales, and Test Taking Strategies
3
The Primigravid Client in Labor
1.
The nurse is managing care of a primigrada at full term who is in active labor. What should be included in developing the plan of care for this client?■ 1. Oxygen saturation monitoring every half hour.
■ 2. Supine positioning on back, if it is comfortable.
■ 3. Anesthesia/pain level assessment every 30 minutes.
■ 4. Vaginal bleeding, ROM assessment every shift.
2.
The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks’ gestation who is admitted to the birthing center in the fi rst stage of labor. The nurse should monitor the client’s fetal heart rate pattern at which of the following intervals?■ 1. Every 15 minutes during the latent phase.
■ 2. Every 30 minutes during the active phase.
■ 3. Every 60 minutes during the initial phase.
■ 4. Every 2 hours during the transition phase.
3.
Assessment reveals that the fetus of a mul- tigravid client is at + 1 station and 8 cm dilated.Based on these data, the nurse should fi rst:
■ 1. Ask anesthesia to increase epidural rate.
■ 2. Assist the client to push if she feels the need to do so.
■ 3. Encourage the client to breathe through the urge to push.
■ 4. Support family members in providing comfort measures.
4.
Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which of the following behaviors during this phase of labor?■ 1. Excitement.
■ 2. Loss of control.
■ 3. Numbness of the legs.
■ 4. Feelings of relief.
5.
The nurse is explaining to a primagravida in labor that her baby is in a breech presentation, with the baby’s presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how her baby is positioned?● 1.
● 2.
● 3.
● 4.
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6.
While caring for a moderately obese primi- gravid client in active labor at term, the nurse should monitor the client for signs of which of the following?■ 1. Hypotonic refl exes.
■ 2. Increased uterine resting tone.
■ 3. Soft tissue dystocia.
■ 4. Increased fear and anxiety.
7.
The nurse is caring for a primigravid client in active labor at 42 weeks’ gestation. The client has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to this client by:■ 1. Changing her pushing position every 15 minutes.
■ 2. Notifying the health care provider of her cur- rent status.
■ 3. Continuing with current pushing technique.
■ 4. Assessing the client’s current pain and fetal status.
8.
The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication?■ 1. Resting period of 2 minutes between contractions.
■ 2. Normal patellar and elbow refl exes for the past 2 hours.
■ 3. Softening of the cervix and beginning effacement.
■ 4. Leaking of clear amniotic fl uid in small amounts.
9.
A primigravid client is admitted as an out- patient for an external cephalic version. The nurse should assess the client for which of the following contraindications for the procedure?■ 1. Multiple gestation.
■ 2. Breech presentation.
■ 3. Maternal Rh-negative blood type.
■ 4. History of gestational diabetes.
10.
A primigravida is admitted to the labor area with ruptured membranes and contractions occur- ring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client’s contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:■ 1. The cervix will begin to dilate 2 centimeters per hour.
■ 2. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
■ 3. The cervix will change from fi rm to soft, efface to 40% to 50%, and move from a poste- rior to anterior position.
■ 4. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
11.
A primigravid client in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically, which of the following would be the best position for the client to assume?■ 1. Dorsal recumbent.
■ 2. Lithotomy.
■ 3. Hands and knees.
■ 4. Squatting.
12.
A 21-year-old primigravid client at 40 weeks’gestation is admitted to the hospital in active labor.
The client’s cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
■ 1. Impaired urinary elimination related to nothing-by-mouth status.
■ 2. Risk for injury related to hyperventilation and dizziness.
■ 3. Ineffective coping related to lack of confi - dence.
■ 4. Pain related to increasing frequency and intensity of uterine contractions.
13.
A 24-year-old primigravid client who delivers a viable term neonate is ordered to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?■ 1. The cord lengthens outside the vagina.
■ 2. There is decreased vaginal bleeding.
■ 3. The uterus cannot be palpated.
■ 4. Uterus changes to discoid shape.
14.
A primiparous client, who has just delivered a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following?■ 1. Disappointment in the baby’s gender.
■ 2. Grief over the ending of the pregnancy.
■ 3. A normal response to the birth.
■ 4. Indication of postpartum “blues.”
15.
The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and con- tractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time?■ 1. Resting in the right lateral recumbent posi- tion.
■ 2. Lying in the left lateral recumbent position.
■ 3. Walking around in the hallway.
■ 4. Sitting in a comfortable chair for a period of time.
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16.
Which of the following would the nurse include in the teaching plan for a 16-year-old primi- gravid client in early labor concerning active relax- ation techniques to help her cope with pain?■ 1. Relaxing uninvolved body muscles during uterine contractions.
■ 2. Practicing being in a deep, meditative, sleep- like state.
■ 3. Focusing on an object in the room during the contractions.
■ 4. Breathing rapidly and deeply between contractions.
17.
The nurse is performing effl eurage for a primigravid client in early labor. The nurse should do which of the following?■ 1. Deep kneading of superfi cial muscles.
■ 2. Secure grasping of muscular tissues.
■ 3. Light stroking of the skin surface.
■ 4. Prolonged pressure on specifi c sites.
18.
A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly contraindicated for clients with which of the following?■ 1. Ruptured membranes.
■ 2. Multifetal gestation.
■ 3. Diabetes mellitus.
■ 4. Hypotonic labor patterns.
19.
A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fi brosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fi brosis is:■ 1. X-linked recessive and the disease will only occur if the baby is a boy.
■ 2. X-linked dominant and there is no likelihood of the baby having cystic fi brosis.
■ 3. Autosomal recessive and that unless the baby’s father has the gene, the baby will not have the disease.
■ 4. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.
20.
The physician orders an amniocentesis for a primigravid client at 35 weeks’ gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?■ 1. Amount of bilirubin present.
■ 2. Presence of red blood cells.
■ 3. Barr body determination.
■ 4. Lecithin-sphingomyelin (L/S ratio).
21.
Assessment of a 15-year-old primigravid client at term in active labor reveals cervical dilation at 7 cm with complete effacement. The nurse should assess the client for which of the following fi rst?■ 1. Uterine inversion.
■ 2. Cephalopelvic disproportion (CPD).
■ 3. Rapid third stage of labor.
■ 4. Decreased ability to push.
22.
A 19-year-old primigravid client at 38 weeks’gestation is admitted to the hospital in active labor that began 8 hours ago. When the client’s cervix is 7 cm dilated and the presenting part is at +1 station, the client tells the nurse, “I need to push!” Which of the following would the nurse do next?
■ 1. Use the McDonald procedure to widen the pelvic opening.
■ 2. Increase the rate of oxygen and intravenous fl uids.
■ 3. Instruct the client to use a pant-blow pattern of breathing.
■ 4. Tell the client to push only when absolutely necessary.
23.
Which of the following would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia?■ 1. Giving frequent sips of water.
■ 2. Applying extra blankets for warmth.
■ 3. Providing frequent perineal cleansing.
■ 4. Offering encouragement and support.
24.
To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which of the following cranial sutures?■ 1. Sagittal.
■ 2. Lambdoidal.
■ 3. Coronal.
■ 4. Frontal.
25.
After a lengthy labor process, a primigravid client delivers a healthy newborn boy with a moder- ate amount of skull molding. Which of the following would the nurse include when explaining to the parents about this condition?■ 1. It is typically seen with breech deliveries.
■ 2. It usually lasts a day or two before resolving.
■ 3. It is unusual when the brow is the presenting part.
■ 4. Surgical intervention may be necessary to alleviate pressure.
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26.
A primiparous client has just delivered her baby. The physician has informed the labor nurse that he believes the uterus has inverted. Which of the following would help to confi rm this diagnosis?Select all that apply.
■ 1. Hypotension.
■ 2. Gush of blood from the vagina.
■ 3. Intense, severe, tearing type of abdominal pain.
■ 4. Uterus is hard and in a constant state of con- traction.
■ 5. Inability to palpate the uterus.
■ 6. Diaphoresis.
27.
After delivery of a viable neonate, a 20-year- old primiparous client comments to her mother and the nurse about the baby. Which of the following comments would the nurse interpret as a possible sign of potential maternal-infant bonding problems?■ 1. “He’s got my funny-looking ears!”
■ 2. “I think my mother should give him the fi rst feeding.”
■ 3. “He’s a lot bigger than I expected him to be.”
■ 4. “I want to buy him a blue outfi t to wear when we get home.”
28.
Assessment of a 23-year-old primigravid cli- ent at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?■ 1. Input from the large sensory fi bers opens the gate.
■ 2. Labor pain is a matter of individual perception.
■ 3. Slow abdominal breathing can open the gate.
■ 4. The gating mechanism is in the spinal cord.
29.
The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience which of the following?■ 1. No pain.
■ 2. Sharp pain.
■ 3. Light pain.
■ 4. Moderate pain.
30.
The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess:■ 1. Fetal heart rate variability.
■ 2. Cervical dilation again.
■ 3. Status of membranes.
■ 4. Bladder status.
31.
For the past 8 hours, a 20-year-old primi- gravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability.After determining that the client is still in the latent phase of labor, the nurse should observe the client for:
■ 1. Exhaustion.
■ 2. Chills and fever.
■ 3. Fluid overload.
■ 4. Meconium-stained fl uid.
32.
A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occip- itoposterior (LOP) position requests pain relief for severe back pain. The nurse should:■ 1. Provide fi rm pressure to the client’s sacral area.
■ 2. Prepare the client for a cesarean delivery.
■ 3. Prepare the client for a precipitate delivery.
■ 4. Maintain the client in a left side-lying position.
33.
A primigravid client in active labor has had no anesthesia. The client’s cervix is 7 cm dilated, and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change from slow chest breathing to which of the following?■ 1. Rapid, shallow chest breathing.
■ 2. Deep chest breathing.
■ 3. Rapid pant-blow breathing.
■ 4. Slow abdominal breathing.
34.
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks’ gesta- tion. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appear- ing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:■ 1. Metabolic alkalosis.
■ 2. Metabolic acidosis.
■ 3. Respiratory alkalosis.
■ 4. Respiratory acidosis.
35.
The physician orders scalp stimulation of the fetal head for a primigravid client in active labor.When explaining to the client about this procedure, which of the following would the nurse include as the purpose?
■ 1. Assessment of the fetal hematocrit level.
■ 2. Increase in the strength of the contractions.
■ 3. Increase in the fetal heart rate and variability.
■ 4. Assessment of fetal position.
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36.
The nurse is caring for a primigravid client in active labor who has had two fetal blood samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis when the scalp blood pH is below which of the following?■ 1. 7.5.
■ 2. 7.4.
■ 3. 7.3.
■ 4. 7.2.
37.
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client complains of severe back pain during this phase of labor. The nurse explains that the client’s severe back pain is most likely caused by the fetal occiput being in a position that is identifi ed as which of the following?■ 1. Breech.
■ 2. Transverse.
■ 3. Posterior.
■ 4. Anterior.
38.
The nurse assesses a primiparous client in labor for 20 hours. The nurse identifi es late decel- erations on the monitor and initiates standard pro- cedures for the labor client with this wave pattern.Which interventions should the nurse perform?
Select all that apply.
■ 1. Administering oxygen via mask to the client.
■ 2. Questioning the client about the effectiveness of pain relief.
■ 3. Placing the client on her side.
■ 4. Readjusting the monitor to a more comfort- able position.
■ 5. Applying an internal fetal monitor to help identify the cause of the decelerations.
39.
When performing Leopold’s maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?■ 1. First maneuver.
■ 2. Second maneuver.
■ 3. Third maneuver.
■ 4. Fourth maneuver.
40.
Before placing the fetal monitoring device on a primigravid client’s fundus, the nurse performs Leopold’s maneuvers. When performing the third maneuver, the nurse explains that this maneuver is done for which of the following reasons?■ 1. To determine whether the fetal presenting part is engaged.
■ 2. To locate the fetal cephalic prominence.
■ 3. To distinguish between a breech and a cephalic presentation.
■ 4. To locate the position of the fetal arms and legs.
41.
A primigravid client in active labor with a fetus in LOP position complains of severe back pres- sure. Which of the following would be the priority nursing diagnosis for this client?■ 1. Anxiety related to fear of maternal-fetal out- comes.
■ 2. Ineffective coping related to lack of experi- ence in labor.
■ 3. Urinary retention related to prolonged labor process.
■ 4. Pain related to occipitoposterior position and prolonged fetal descent.
42.
One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primi- gravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client’s blood pressure is 136/92 mm Hg. Which of the fol- lowing would the nurse do fi rst?■ 1. Continue to monitor the client’s fundus every 15 minutes.
■ 2. Ask the physician for an order for methyler- gonovine (Methergine).
■ 3. Immediately notify the physician of the cli- ent’s symptoms.
■ 4. Change the client’s perineal pads every 15 minutes.