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RN Nursing School · Maternal-Newborn · 370 questions

Intrapartum practice questions

Every question below is free to read with its full rationale. For timed sets, the rest of the bank and progress tracking on Intrapartum, practise in the app.

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  1. 1A nurse is performing a vaginal exam on a client who is in labor. The nurse palpates the presenting part and determines the fetus is in a face presentation. Which of the following should the nurse expect to occur during labor?Answer →
  2. 2A labor and delivery nurse is teaching a nursing student about the anticipated care of a maternal client with ruptured membranes during active labor. Which of the following statements by the student indicates an understanding of the teaching?Answer →
  3. 3A nurse wishes to assess fetal heart tones and has determined the fetal position is left occiput anterior (LOA). To which of the following areas of the patient's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity (PMI) of the fetal heart?Answer →
  4. 4The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief?Answer →
  5. 5Which of the following symptoms is most indicative of lightening in a nulliparous client?Answer →
  6. 6A nurse places a tocodynamometer (TOCO) transducer on the client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?Answer →
  7. 7A client is experiencing prolonged labor, with ruptured membranes. What is the nurse's priority concern?Answer →
  8. 8A nurse is caring for a primigravid client who is at 36 weeks of gestation and asks, "How will I know if I am in labor?" Which of the following manifestations of true labor should the nurse discuss with the client? (Select All that Apply.)Answer →
  9. 9A nurse is reviewing the electronic fetal monitor strip for a client who is at 38 weeks of gestation and is in labor. Which of the following findings indicate to the nurse that the fetus is experiencing recurring late decelerations?Answer →
  10. 10A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?Answer →
  11. 11A nurse on a labor and delivery unit is teaching a newly licensed nurse about operative vaginal birth. Which of the following statements by the newly licensed nurse indicates the teaching was effective?Answer →
  12. 12A nurse is caring for several clients in the labor and delivery unit. The nurse must assess which of the following clients first?Answer →
  13. 13A nurse is caring for a multiparous client in the latent phase of the first stage of labor who reports mild contractions and desires comfort measures. The client also expresses concern about the possibility of prolonged labor due to prior history. Which nursing intervention best addresses both comfort and potential labor progression?Answer →
  14. 14Which maternal treatment would the nurse suspect occurred when an infant demonstrates hypotonia and lethargy after birth?Answer →
  15. 15A laboring client is not progressing despite adequate contractions. The provider inserts an intrauterine pressure catheter (IUPC). Which statement by the nurse best describes the purpose of the IUPC?Answer →
  16. 16A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do?Answer →
  17. 17After delivery, the nurse palpates the fundus and notices it has become firm and globular and is rising in the abdomen. What does this indicate?Answer →
  18. 18A client at term reports irregular abdominal tightening that goes away with rest and hydration. Which finding should the nurse explain?Answer →
  19. 19Which intervention may unintentionally increase a client's pain perception during labor?Answer →
  20. 20A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?Answer →
  21. 21The nurse is providing care for a nulliparous client who has been pushing for 3.5 hours. The nurse suspects fetal dystocia and understands that which of the following are complications of this finding? (Select all that apply)Answer →
  22. 22A nurse on a labor and delivery unit is preparing to assist in several births. Which of the following clients should the nurse recognize as most likely to experience an operative vaginal birth?Answer →
  23. 23A nurse is assisting with collecting data from the electronic fetal monitor strip for a client at 38 weeks of gestation and is in labor. Which of the following findings indicate to the nurse that the fetus is experiencing recurring late decelerations?Answer →
  24. 24Nurse is monitoring a laboring client. The fetal heart rate tracing shows absent variability and recurrent late decelerations. How should the nurse interpret this finding?Answer →
  25. 25A nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following?Answer →
  26. 26A nurse is educating a novice nurse about the use of nitrous oxide during labor. Which of the following statements by the novice nurse requires follow up by the nurse?Answer →
  27. 27Which is the correct sequence of the cardinal movements of labor?Answer →
  28. 28The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?Answer →
  29. 29The nurse is educating a group of labor and delivery nurses about anaphylactoid syndrome of pregnancy. Which statement by the nurse indicates a need for further education?Answer →
  30. 30A client in the second stage of labor reports to a nurse that they are feeling pain and pressure in their pelvis and perineum. Which of the following should the nurse understand that this pain is caused by?Answer →
  31. 31When assessing the frequency of contractions of a client in active labor, the nurse should assess the interval between which of the following?Answer →
  32. 32A nurse is providing an antepartum education class for several clients. Which of the following interventions should the nurse recommend to manage pain during the first stage of labor?Answer →
  33. 33Which statement correctly identifies the four stages of labor?Answer →
  34. 34The nurse is caring for a client in the active phase of labor. Which assessment finding requires immediate action?Answer →
  35. 35A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?Answer →
  36. 36Which is the method of childbirth that helps prevent the fear-tension-pain cycle by using slow abdominal breathing in early labor and rapid chest breathing in advanced labor?Answer →
  37. 37A nurse is caring for a client who is in the fourth stage of labor and received an epidural during labor. Which of the following actions should the nurse take before ambulating the client to the bathroom?Answer →
  38. 38A provider orders ceftriaxone (Rocephin) 1 g in 100 mL of normal saline to infuse over 30 minutes using an IV pump. At what rate (mL/hr) should the nurse set the IV infusion pump? (Round to the nearest whole number.)Answer →
  39. 39A nurse is assisting in the care of a client in labor whose provider is at the bedside for a vaginal examination. The provider reports the fetus is in a face presentation. Which of the following should the nurse expect to occur during labor?Answer →
  40. 40For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.Answer →
  41. 41A nurse is caring for a client who is experiencing shoulder dystocia. Which of the following potential effects of shoulder dystocia should the nurse anticipate for the client giving birth and the newborn (Select All that Apply.)Answer →
  42. 42A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta. Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?Answer →
  43. 43A client is in the second stage of labor and is fatigued. What nursing action best supports effective pushing?Answer →
  44. 44A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?Answer →
  45. 45A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse gather from the woman's prenatal record when planning nursing care? (Select all that apply.)Answer →
  46. 46The nurse is caring for a group of clients in labor. Which client is most appropriate for the nurse to administer nalbuphine?Answer →
  47. 47Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.Answer →
  48. 48A nurse reviews the most recent assessment findings. What actions should the nurse take. (Select all that apply.)Answer →
  49. 49A nurse is caring for a client in active labor with an epidural in place. Which assessment requires immediate action?Answer →
  50. 50A nurse is assessing a client who is at 38 weeks of gestation. Upon admission 2 hr ago the client had irregular contractions, was dilated 2 cm, and was at -1 cm station. Which of the following findings indicates progression in labor?Answer →
  51. 51A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see?Answer →
  52. 52Which degree of laceration extends through the anal sphincter and rectal mucosa?Answer →
  53. 53The nurse is working in the labor and delivery unit. For which client would an induction of labor be appropriate?Answer →
  54. 54A laboring client with ruptured membranes for 24 hours develops a temperature of 101.8°F (38.8°C), fetal tachycardia of 175 bpm, and uterine tenderness. What is the nurse's priority action?Answer →
  55. 55A nurse is preparing to administer Lortab (hydrocodone/acetaminophen) to a patient post-cesarean section. The prescription is for 7.5 mg hydrocodone every 4 hours as needed for pain. The medication available contains 7.5 mg hydrocodone per 15 mL of liquid. The nurse calculates the dose to administer using the desired over have formula. If the patient requests pain medication, what volume in milliliters should the nurse administer?Answer →
  56. 56A nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:Answer →
  57. 57A nurse is reviewing the electronic fetal monitor strip for a client who is at 38 weeks gestation and is in labor. Which of the following findings indicates to the nurse that the fetus is experiencing recurrent late decelerations?Answer →
  58. 58A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response?Answer →
  59. 59A nurse is discussing visceral pain during labor with a newly licensed nurse. Which of the following causes of pain stated by the newly licensed nurse would require follow-up from the nurse?Answer →
  60. 60A nurse is administering a 500 mL bolus of lactated Ringer's for a client who is in labor and has a prescription for spinal anesthesia. Which of the following findings indicates that the IV bolus was effective?Answer →
  61. 61A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate (Nadir) occurs after the peak of the contraction. Which of the following actions should the nurse take first?Answer →
  62. 62A nurse is preparing a client to receive an epidural for pain management during labor. Which of the following actions is most important in preventing maternal hypotension?Answer →
  63. 63A client in active labor receives a prescription for oxytocin 12 milliunits/min IV. The IV bag contains "Oxytocin 5 units in lactated Ringer's 500 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)Answer →
  64. 64Before performing an amniotomy for a client experiencing dysfunctional labor, which assessment is the highest priority to evaluate?Answer →
  65. 65A nurse is caring for a client who is having a vacuum-assisted birth. Which of the following actions should the nurse take?Answer →
  66. 66A nurse is teaching a prenatal class, and a learner asks the nurse to explain what happens during a prolapsed umbilical cord. Which of the following statements should the nurse make?Answer →
  67. 67The nurse sees the fetal head at the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following?Answer →
  68. 68A client presents labor and delivery for evaluation. Upon placing the fetal monitor, the nurse notes a consistent fetal heart rate (FHR) of 170-180 bpm. What is the nurse's initial response, based on the most likely cause of fetal tachycardia?Answer →
  69. 69A nurse is caring for a laboring client receiving an amnioinfusion to relieve variable decelerations. Which nursing action is most important during this procedure?Answer →
  70. 70A nurse is assessing a client in labor. The client reports moderate to strong contractions every 3-4 minutes, and cervical examination reveals 7 cm dilation and 80% effacement. Which statement is most accurate?Answer →
  71. 71Which action will the nurse take to prevent a further reduction of blood pressure when the maternal blood pressure of a patient receiving administration of epidural anesthesia changes from 135/85 mm Hg to 100/70 mm Hg? Select all that apply. One, some, or all responses may be correct.Answer →
  72. 72A nurse is caring for a client who is in labor and is receiving epidural analgesia. Which of the following changes in the FHR should the nurse report to the provider?Answer →
  73. 73Your patient is receiving oxytocin to augment her labor. You need to set her IV pump to deliver 10 milliunits of oxytocin an hour. The premixed bag of LR with oxytocin gives you a concentration of 1 milliunit oxytocin/3ml. How many ml/hr should you set your pump at?Answer →
  74. 74The nurse is monitoring the fetal heart rate on the fetal monitor and the baseline is 129 beats per minute. The patient questions the result of the heart rate. What information would the nurse provide?Answer →
  75. 75A client is experiencing prolonged labor, with ruptured membranes. What is the nurse's priority concern?Answer →
  76. 76A nurse is assisting with the care of a client who is in labor and has an external electronic fetal monitor. The nurse observes that the fetal heart rate begins to decelerate after the contraction has started, with the lowest point of the deceleration occurring after the peak of the contraction. Which of the following actions should the nurse take first?Answer →
  77. 77Which action Will the nurse take When a patient in labor develops hypotension after receiving a lumbar epidural for pain management?Answer →
  78. 78A nurse is performing an assessment of a patient scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician or midwife?Answer →
  79. 79A laboring client is visibly anxious, breathing rapidly, and states she "cannot focus" during contractions. The fetal heart rate is reassuring, but uterine contractions remain irregular and weak. Which nursing intervention is most appropriate to promote more effective contractions?Answer →
  80. 80A nurse is caring for a woman in active labor who reports increasing pain with contractions and wants to avoid medication. Which nursing action would be most effective in promoting comfort at this stage of labor?Answer →
  81. 81A nurse is caring for a client in spontaneous labor and has an external fetal monitor to record FHR and uterine contractions. The nurse is observing early decelerations, after an amniotomy performed by the MD, variable decelerations are noted on the monitor strip. Which intervention the nurse must take?Answer →
  82. 82A nurse is caring for a client who is 42 weeks of gestation. After an obstetric assessment, the physician concluded that the Bishop score is 9. Based on this score, which of the following orders should the nurse expect?Answer →
  83. 83The placenta is delivered 15 minutes after the baby. The nurse knows this describes which stage of labor?Answer →
  84. 84A primigravida's membranes rupture spontaneously. The nurse's first action is to:Answer →
  85. 85A practical nurse is gathering data from the client on incorporating cultural practices into their pain management during labor. Which of the following statements by the nurse is most appropriate?Answer →
  86. 86Immediately after birth, the fundus becomes globular, rises in the abdomen, the umbilical cord lengthens, and there is a sudden gush of blood. What is the best interpretation?Answer →
  87. 87A homeless man is brought to the ER after falling in the street and hitting his head. On assessment, the nurse documents lack of muscle coordination, poor vision, and moderate dementia. Based on these data, the diagnosis of which sexually transmitted infection (STI) is suggested?Answer →
  88. 88A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?Answer →
  89. 89A nurse is assisting with the care of a client who is in labor. Which of the following manifestations indicate that the client may be experiencing a uterine rupture?Answer →
  90. 90A nurse is prioritizing client care. Complete the following sentence by using the lists of options. The nurse should first address the client's [blank1] followed by the client's [blank2]Answer →
  91. 91A nurse is discussing nonpharmacological pain management during labor with a client. Which of the following statements by the client indicates an understanding of the teaching?Answer →
  92. 92The nurse auscultates a fetal heart rate of 150 beats per minute (bpm) on a client in early labor. Which of the following actions by the nurse is appropriate?Answer →
  93. 93A nurse is reviewing the chart of a client who is in the first stage of labor. Which of the following interpretations should the nurse make from the results of the last vaginal examination stating, "6 cm/70%/-1"?Answer →
  94. 94A nursing student is giving a presentation to their class about uterine rupture. Which of the following points should the student include in the presentation to explain what happens during a uterine rupture?Answer →
  95. 95A nurse is caring for a client in early labor. Which finding indicates the onset of true labor?Answer →
  96. 96A nurse is admitting a client who presented to a labor and delivery unit reporting labor contractions. When conducting the initial assessment, which of the following findings indicates to the nurse that the fetus is likely in a breech presentation?Answer →
  97. 97Which equipment is used for internal fetal monitoring? (Select all that apply.)Answer →
  98. 98Which is the primary nursing action for a pregnant patient prescribed oxytocin?Answer →
  99. 99A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occiput anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?Answer →
  100. 100A client presents to labor and delivery triage because she is in labor. The client is from out of town, and the nurse must document the client's complete history. The nurse asks the client if this is her first pregnancy. The client tells the nurse that this is her fifth pregnancy. The nurse asks the outcome of her previous pregnancies, and the client states, "I had my first baby at 41 weeks. My second was born at 37 weeks, and then I got pregnant with twins and had them at 33 weeks. I had another baby after the twins that was born at 19 weeks." Which of the following is the correct documentation of the client's GTPAL status?Answer →
  101. 101A primigravida client in labor appears extremely anxious, grimacing, and frequently requesting pain medication. How might her psychological state (psyche) affect labor?Answer →
  102. 102A nurse is assisting with the care of a client who is pregnant and in the labor and delivery unit. The nurse is contacting the provider regarding the client's status. (Based on the provided Medical History, Vital Signs, and Nurses' Notes) Which of the following findings should the nurse include in the report? (Select 4)Answer →
  103. 103Which assessment finding is the best indication that a client is in active labor?Answer →
  104. 104A nurse is assessing a client in early labor. The cervix is 70% effaced and 3 cm dilated, and the client is a first-time mother. Which interpretation of cervical change is most accurate?Answer →
  105. 105A patient is prescribed 750 mL of 0.9% NaCl to be infused over 5 hours. The drop factor of the tubing is 15 drops per mL. Determine the infusion rate in drops per minute. Round to a whole number.Answer →
  106. 106A nurse is receiving the report of a client who is in active labor and the leaving shift assessment is as follows: 8cm, 100%, and (+2). Which of the following is the correct interpretation of this client's assessment?Answer →
  107. 107A nurse is planning care for a client who is scheduled for a cesarean birth. Which of the following interventions should the nurse include in the plan of care?Answer →
  108. 108A client is in advanced labor at 9 cm dilation and requests IV morphine for pain. Fetal heart rate tracing is reassuring. Which nursing action best demonstrates safe, evidence-based practice?Answer →
  109. 109Which pelvic type is most favorable for vaginal delivery?Answer →
  110. 110A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following?Answer →
  111. 111A nurse is assessing the client. Which of the following findings require follow-up? Select the 3 options that apply.Answer →
  112. 112A nurse administers fentanyl to a client in labor for pain management. The client begins to show symptoms of respiratory distress. Which of the following would be appropriate for the nurse to administer?Answer →
  113. 113A nurse is assisting in in the care of a client who is at risk for shoulder dystocia. Which of the following manifestations indicate that shoulder dystocia is occurring?Answer →
  114. 114A laboring client's fetal presenting part is palpated 2 cm above the ischial spines. What is the correct station?Answer →
  115. 115The nurse is caring for a laboring client at 38 weeks gestation who suddenly reports feeling something in the vagina after her membranes rupture spontaneously. The fetal heart rate drops to 60 beats/minute. What should be the nurse's priority assessment?Answer →
  116. 116A nurse is reviewing a fetal monitoring strip and recognizes late decelerations. Which of the following actions should the nurse take at this time?Answer →
  117. 117A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?Answer →
  118. 118A 17-year-old client has been admitted to the healthcare facility after a sexual assault. Which nursing intervention is involved in caring for this client?Answer →
  119. 119A pregnant client reports contractions that began irregularly but have become stronger and closer together over the past several hours. The contractions persist despite rest and hydration. On assessment, the cervix has progressed from 3 cm/70% to 4 cm/90%. Which finding is most indicative of true labor?Answer →
  120. 120A nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?Answer →
  121. 121A nulliparous client is admitted for an induction with a Bishop score of 8. An oxytocin infusion was started at 2 milliunits/minute 5 hours ago and is currently at 20 milliunits/minute for the last hour. The nurse performs a vaginal exam which shows no cervical change for the past hour. The contractions are occurring every 7 to 9 minutes and mild by palpation. Which action should the nurse take?Answer →
  122. 122The charge nurse is reviewing staffing for the next shift. Which client has the greatest chance of success for a vaginal birth after cesarean (VBAC)?Answer →
  123. 123The healthcare provider prescribed oxytocin infusion to run at 12 milliunits/min. The pharmacy delivered 30 units of oxytocin in 500 mL of normal saline. At what rate will the nurse set the infusion? ___ mL/hour (If needed, round the answer to the nearest whole number.)Answer →
  124. 124A nurse is assessing a client in labor. The client reports moderate to strong contractions every 3-4 minutes, and cervical examination reveals 7 cm dilation and 50% effacement. Which statement is most accurate?Answer →
  125. 125A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving Oxytocin IV for labor augmentation at 5 mu/hr. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct nursing intervention for this finding?Answer →
  126. 126A nurse is caring for a client in the labor and delivery unit who is at 39 weeks of gestation. During the vaginal exam, the nurse recorded the following data: Cervix dilation 6 cm, 3 uterine contractions in 10 minutes, lasting 60 seconds each, and 100% cervical effacement. The nurse must document these findings in the client record as: Which stage of labor?Answer →
  127. 127A nurse is assisting with the care of a client who is reporting pain and pressure in their perineum. Which of the following should the nurse understand that this pain is caused by?Answer →
  128. 128A laboring client is about to receive an epidural for pain management. Which nursing action is most important before administering the epidural?Answer →
  129. 129A client who is 36 weeks' gestation calls the clinic and states, "I'm not sure if I'm really in labor or if it is false labor." Which is the best response by the nurse?Answer →
  130. 130A nurse is caring for a client in labor who states, "I am really afraid of giving birth," and begins crying. The client is currently in active labor and vaginal exam reveals 7 cm dilation, 80% effacement, and 0 station. Which of the following factors of labor should the nurse address?Answer →
  131. 131The nurse caring for a client with a prolapsed cord should expect which priority preparation?Answer →
  132. 132A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider (HCP) prescribes an oxytocin drip. Which data is most important for the nurse to monitor?Answer →
  133. 133Which complication will the nurse monitor for in a patient in labor receiving oxytocin?Answer →
  134. 134A pregnant client at term called the labor suite at 1900, questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated:Answer →
  135. 135The nurse is prioritizing clients who require immediate cesarean section. Which client should the nurse identify as the highest priority for cesarean delivery?Answer →
  136. 136A client is 24 hours post-cesarean birth. She reports increasing abdominal pain unrelieved by analgesics, rigid abdomen, and decreased urine output. What is the nurse's priority action?Answer →
  137. 137A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?Answer →
  138. 138A nurse is caring for a client who is in a trial of labor for vaginal birth after cesarean (VBAC). The client reports a sudden tearing pain in their back and side that does not feel like a uterine contraction. Which of the following findings indicates the client may be experiencing a uterine rupture?Answer →
  139. 139A nurse assisting in the care of a client, places the tocodynamometer (TOCO) on the client's abdomen and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?Answer →
  140. 140A clinic nurse is scheduling several clients with breech presentation for external cephalic version (ECV). While reviewing the client's charts, the nurse notes which of the following client's should not be offered an ECV? (Select all that apply.)Answer →
  141. 141A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status?Answer →
  142. 142When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior (LOA) position. Which is the best position for the nurse to place a fetoscope to hear the fetal heart rate?Answer →
  143. 143A pregnant client at 38 weeks gestation reports experiencing regular contractions that increase in intensity and are felt starting in the lower back and radiate to the lower abdomen. The nurse notes a bloody show and cervical dilation on examination. Which nursing action is the priority based on these findings?Answer →
  144. 144A multiparous client in active labor receiving an epidural develops moderate hypotension. Which of the following interventions would the nurse anticipate the physician will order?Answer →
  145. 145A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?Answer →
  146. 146In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/minute from a rate of 160 beats/minute earlier in the pregnancy. What is the nurse's first action?Answer →
  147. 147A nurse is performing a nonstress test for a client who is at 38 weeks of gestation. The fetal monitor tracing reveals a series of late decelerations. Which of the following interventions should the nurse implement first?Answer →
  148. 148A nurse is caring for a client who is in labor and has an umbilical cord prolapse. Which action should the nurse take?Answer →
  149. 149A patient is prescribed 1 g of medication in 250 mL of IV fluid to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. How many gtt/min should the nurse set the manual infusion rate? (Round to the nearest whole number).Answer →
  150. 150The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and -2 station. Which of the following has the nurse palpated?Answer →
  151. 151A client is experiencing prolonged labor, with ruptured membranes. What is the nurse's priority concern?Answer →
  152. 152The client you are caring for, declined electronic fetal monitoring, so you must palpate her contractions to determine frequency, intensity, and duration. During a contraction, you palpate her fundus and find that the uterine wall cannot be indented. How would you classify the intensity of this contraction?Answer →
  153. 153A nurse is preparing to administer 500 mL of IV fluid over 2 hours using manual IV tubing with a drop factor of 15 gtt/mL. What should the drip rate be in gtt/min?Answer →
  154. 154A nurse is providing care to a client who is in the early phase of labor and reporting pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse perform? (Select all that apply.)Answer →
  155. 155The nurse reviews a fetal presentation diagram showing hips flexed, knees extended, feet near the fetal head. Which type of breech does this represent?Answer →
  156. 156A nurse on a labor and delivery unit is preparing to assist in several births. Which of the following clients should the nurse recognize as most likely to experience an operative vaginal birth?Answer →
  157. 157A pregnant client at 36 weeks gestation is experiencing irregular contractions and asks the nurse how to distinguish false labor from true labor. Which explanation should the nurse provide to help the client identify false labor?Answer →
  158. 158A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?Answer →
  159. 159A nurse on a labor and delivery unit is teaching a newly licensed nurse about operative vaginal birth. Which of the following statements by the newly licensed nurse indicates the teaching was effective?Answer →
  160. 160A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has chorioamnionitis for a staphylococcal infection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL/hrAnswer →
  161. 161A nurse is assisting with the care of a client in the second stage of labor who does not want any tools used to assist with the vaginal birth. Which of the following interventions should the nurse understand will help prevent an assisted vaginal birth? (Select All that Apply.)Answer →
  162. 162The nurse is caring for a client in the active phase of labor. Which assessment finding requires immediate action?Answer →
  163. 163A G2T1P0A0L1 client presents to labor and delivery at 40 weeks gestation with reports of a sudden gush of clear fluid from the vagina but denies contractions. The nurse applies the external monitors, and the fetal heart rate is reassuring. The provider is notified. Which orders would the nurse anticipate receiving? (Select all that apply)Answer →
  164. 164A nurse on a labor unit is admitting a client who is in a supine position and reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 90/52 mm Hg. Bleeding is not noted. Which of the following is the priority action for the nurse to take?Answer →
  165. 165A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?Answer →
  166. 166A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?Answer →
  167. 167Which nursing intervention is appropriate for a postpartum patient experiencing a residual postdural headache following a saddle block during delivery?Answer →
  168. 168A nurse is assisting in the care of a client who had an episiotomy during labor after the fetal heart had shown multiple decelerations. Which of the following explanations should the nurse provide to explain the reason for this procedure?Answer →
  169. 169During a vaginal examination, the nurse palpates the fetal buttocks facing the left posterior and determines they are 1 cm above the ischial spines. How should the nurse document the fetal station?Answer →
  170. 170A laboring client with a documented history of trauma becomes visibly distressed during a vaginal exam and states, "I need a break." Vital signs and fetal heart rate are reassuring. Which nursing action best reflects trauma-informed care?Answer →
  171. 171Which assessment finding indicates the fetus is adequately oxygenated?Answer →
  172. 172A nurse is caring for a client who is in the third stage of labor. The provider is applying traction to the umbilical cord while applying fundal pressure. Which of the following is a potential complication of these actions?Answer →
  173. 173During labor augmentation with oxytocin, which assessment finding requires immediate intervention?Answer →
  174. 174The nurse notices variable decelerations on the fetal monitor. Which nursing action is appropriate during the second stage of labor?Answer →
  175. 175A nurse is caring for a client who is receiving 1 milliunit/min of oxytocin for the induction of labor. The provider prescription reads to increase the rate by 1 milliunit per/min every 30 min until the client demonstrates an expected labor pattern. Which of the following findings indicates the nurse should titrate the infusion rate to 2 milliunits/min after the first 30 min?Answer →
  176. 176The nurse is assisting with the delivery of a macrosomic infant for a client at 41 weeks gestation. After delivery of the fetal head, the provider states that shoulder dystocia is present. The nurse observes the following: Fetal head is delivered, but the shoulders remain impacted at the symphysis pubis. The provider instructs the client to push harder. The provider attempts to pull on the fetal head to deliver the body. Which of the following actions should the nurse question?Answer →
  177. 177The nurse is triaging a 38-week pregnant client who arrived at the labor and delivery unit with contractions. What should the nurse include in the triage assessment of the client? Select all that apply.Answer →
  178. 178A provider orders 750 mL of normal saline to be infused over 5 hours. The IV tubing has a drop factor of 20 drops per mL. What is the correct infusion rate in drops per minute?Answer →
  179. 179A nurse is caring for a client who has a prescription for metronidazole 250 mg PO three times daily. Available is metronidazole 500 mg tablets. How many tablet(s) should the nurse plan to administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  180. 180Which fetal heart rate pattern is most consistent with umbilical cord compression?Answer →
  181. 181The nurse notes variable decelerations on the fetal monitor strip. What is the most appropriate initial action?Answer →
  182. 182The nurse has administered the prescribed medication IV bolus. Which of the following actions should the nurse take? Select the 3 actions the nurse should take.Answer →
  183. 183A woman has just arrived at the labor and delivery suite. Before reporting the client's arrival to her primary healthcare practitioner, which of the following assessments should the nurse perform? (Select all that apply.)Answer →
  184. 184A nurse is caring for a full term client in labor who is prescribed continuous fetal monitoring. On examination, the nurse determines the client's membranes are intact. Which of the following assessment methods should the nurse implement?Answer →
  185. 185A nurse is planning to administer misoprostol 50 mcg intravaginally for cervical ripening to a client who is at 40 weeks of gestation. Available is misoprostol 200 mcg tablets. How many tablets should the nurse plan to administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  186. 186A nurse is collecting data from a fetal monitor strip and recognizes late decelerations. Which of the following actions should the nurse expect to be taken at this time?Answer →
  187. 187A nurse is evaluating a client at 39 weeks gestation who reports a sudden surge of energy and has experienced an increase in vaginal discharge tinged with blood. Vital signs reveal mild tachycardia and a slight rise in temperature. Which of the following nursing actions is the most appropriate to prioritize in this situation?Answer →
  188. 188A nurse is caring for a client at 40 weeks gestation during a prenatal visit. The provider has mentioned inducing the client as she is at 40 weeks. Which of the following statements by the client indicates that the client understands the teaching?Answer →
  189. 189A client received an opioid for pain 20 minutes ago and is now in second stage of labor. What is the nurse's priority action?Answer →
  190. 190A patient's tracing shows baseline 130 bpm, moderate variability, recurrent varicab... What is the nurse's first intervention?Answer →
  191. 191A laboring client receiving IV oxytocin develops a contraction pattern characterized by 7 contractions in a 10-minute period with no uterine relaxation between contractions. Fetal heart rate monitoring shows late decelerations. After discontinuing oxytocin, the contractions persist with minimal improvement. What is the nurse's best next action?Answer →
  192. 192A nurse is collecting data from a client who has been diagnosed with trichomonas. Which of the following findings should the nurse identify as a manifestation of trichomonas infection?Answer →
  193. 193A practical nurse is reinforcing education with a client on the benefits of support during labor. Which of the following benefits should the nurse include in their teaching reinforcement? (Select All that Apply.)Answer →
  194. 194A nurse is caring for a client who is at 12 weeks of gestation during an initial prenatal visit. The client asks, "What is a normal fetal heart rate?" Which of the following ranges should the nurse provide?Answer →
  195. 195The nurse reviews chart and assessment data. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.Answer →
  196. 196On labor A laboring client is extremely anxious and tense. She reports fear about the labor process and is unable to relax between contractions. The nurse explains the effects of anxiety. Which statement by the nurse is most accurate?Answer →
  197. 197The nurse is reviewing the fetal heart rate strip below. What intervention should the nurse question?Answer →
  198. 198A laboring client at 41 weeks' gestation is on continuous fetal monitoring. The fetal heart rate shows repetitive variable decelerations during contractions. The provider orders an amnioinfusion. Which explanation should the nurse give to the client about the purpose of this procedure?Answer →
  199. 199A nurse performs a vaginal examination on a laboring client and identifies the fetal presenting part at 0 station. What is the most important clinical implication of this finding for the nurse's care planning?Answer →
  200. 200A nurse notes meconium-stained amniotic fluid. What is the priority assessment?Answer →
  201. 201A nurse is caring for a client who is in active labor. The nurse notes late decelerations in the FHR on the fetal monitor tracing. Which of the following actions should the nurse take first?Answer →
  202. 202The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse prioritize in this situation?Answer →
  203. 203A nurse is monitoring a laboring client in the first stage of labor. Which clinical finding indicates that the first stage of labor has ended and the second stage is beginning?Answer →
  204. 204The nurse is caring for a client in active labor who just had an amniotomy performed. What is the priority nursing action?Answer →
  205. 205The nurse is administering oxytocin for induction. Which finding requires immediate intervention?Answer →
  206. 206A nurse in a prenatal clinic is caring for a client who is 39 weeks gestation. The nurse educates the client on signs of impending labor. What sign should the nurse include in the education?Answer →
  207. 207A nurse is discussing visceral pain during labor with a newly licensed nurse. Which of the following causes of pain stated by the newly licensed nurse would require follow up from the nurse?Answer →
  208. 208A nurse is caring for a client in active labor with an epidural in place. Which assessment requires immediate action?Answer →
  209. 209The nurse is caring for a client who is 4 cm dilated and has not received an epidural or any pain relief medication. Which finding is consistent for this stage of labor?Answer →
  210. 210A nurse is caring for a client during the second stage of labor. The client has been pushing for 2 hours and is exhausted but the fetal had has not moved past a 2+ station. Which of the following is not one of the potential complications associated with using a vacuum extractor to assist in delivery?Answer →
  211. 211Which fetal effect is expected with maternal magnesium sulfate therapy?Answer →
  212. 212A client is entering the second stage of labor. Which nursing action should the nurse plan to implement during this stage?Answer →
  213. 213A client with a twin pregnancy is in labor. After delivery of the first twin, the fetal heart rate of the second twin drops to 90 bpm. What is the nurse's priority action?Answer →
  214. 214What is the most common cause of decreased variability in the fetal heart rate (FHR) lasting 30 minutes or less?Answer →
  215. 215A postpartum client who received epidural anesthesia during labor is experiencing complications related to anesthesia. The nurse should assess the client for which potential complication?Answer →
  216. 216Which FHR decelerations are considered "always bad" and indicate poor placenta perfusion or placenta insufficiency?Answer →
  217. 217The nurse is educating a G1P0 client at 38 weeks gestation who has been diagnosed with cephalopelvic disproportion (CPD). The provider has recommended a scheduled cesarean birth. Which statement by the client indicates the need for further education?Answer →
  218. 218Which pelvic type is most favorable for vaginal delivery?Answer →
  219. 219The nurse is caring for a laboring client. What should the nurse include in the documentation of this fetal monitoring strip below.Answer →
  220. 220Sarah's prescription indicates amoxicillin 250 mg PO every 8 hours. You have an oral suspension available at 400 mg/5 mL. How many milliliters should you administer per dose? (Round to the nearest tenth).Answer →
  221. 221Before applying an internal fetal scalp electrode, the nurse must confirm which condition?Answer →
  222. 222A nurse is caring for several clients during labor that would like to use water therapy for pain management. For which of the following clients should the nurse encourage to find an alternative pain management technique? (Select All that Apply.)Answer →
  223. 223A patient is prescribed 750 mL of 0.9% NaCl to be infused over 5 hours. The drop factor of the tubing is 15 drops per mL. Determine the infusion rate in drops per minute. Round to a whole number 1Answer →
  224. 224A nurse who is assisting in the care of a client during labor suspects that the fetal spine is lying perpendicular to the client spine due to placement of the electronic fetal monitor. Which of the following actions should the nurse expect?Answer →
  225. 225A relaxation technique that can be used during the childbirth experience to decrease maternal pain perception isAnswer →
  226. 226A nurse administers fentanyl to a client in labor for pain management. The client reports nausea. Which of the following interventions should the nurse provide?Answer →
  227. 227A primiparous client in active labor is experiencing slow fetal descent and prolonged second stage labor. Considering maternal pelvic structure factors, which nursing intervention is most appropriate to facilitate fetal passage through the birth canal?Answer →
  228. 228A 39-week-gestational multigravida is admitted to labor and delivery with spontaneous rupture of membranes (SROM) and contractions occurring every 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6 cm, 90% effaced, and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate (FHR) has ranged between 170 and 180 beats/minute. Which action should the nurse implement?Answer →
  229. 229The nurse is providing education about the different movements that a fetus goes through during a vaginal delivery. Which cardinal movement is presented in the picture below?Answer →
  230. 230A term multigravida, who is receiving oxytocin for labor augmentation, is requesting pain medication. Review of the client's record indicates that she was medicated 30 minutes ago with butorphanol tartrate 2 mg IV push and promethazine 25 mg IV push. Vaginal examination reveals that the client's cervical dilation is 3 cm, 70% effaced, and at a 0 station. Which action should the nurse implement?Answer →
  231. 231A laboring client has a Category III fetal heart tracing. According to the Intrapartum Management Decision Model (ABCD), which is the priority action?Answer →
  232. 232A nurse is providing postoperative teaching to a patient who is 12 hours post-cesarean birth. The patient asks how to help prevent abdominal bloating and gas discomfort after surgery. Which intervention should the nurse recommend as the most effective measure to reduce postoperative abdominal distention?Answer →
  233. 233A nurse is caring for a client who is in labor and has spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina. After calling for help, which of the following actions should the nurse take first?Answer →
  234. 234The nurse is caring for a client at 39 weeks gestation who is undergoing labor induction with oxytocin. The fetal heart rate tracing shows tachysystole with late decelerations. What is the most appropriate nursing action?Answer →
  235. 235A client in the second stage of labor reports to a nurse that they are feeling pain and pressure in their pelvis and perinium. Which of the following should the nurse understand that this pain is caused by?Answer →
  236. 236A nurse is caring for a client who is receiving epidural anesthesia. The client is hypotensive with decreased placental perfusion. Which of the following actions should the nurse take?Answer →
  237. 237A nurse observes a laboring client's contractions: Contraction starting at 10:00 ending at 10:01 Contraction starting at 10:04 ending at 10:05 Contraction starting at 10:08 ending at 10:09 Which statement best describes the contraction frequency?Answer →
  238. 238Which statement correctly identifies the four stages of labor?Answer →
  239. 239The labor and delivery nurse educator is teaching a new nurse about vacuum assisted deliveries. Which response by the new nurse indicates a need for further teaching?Answer →
  240. 240A client is in the second stage of labor and is fatigued. What nursing action best supports effective pushing?Answer →
  241. 241A nurse assists with the repositioning of the tocodynamometer (TOCO) several times for a client who is in active labor and whose uterine contraction tracing has not been recording accurately. Which of the following steps should the nurse expect to be taken to obtain an accurate assessment?Answer →
  242. 242A nurse on a labor and delivery unit is reviewing the electronic FHR monitoring strip for a client who is in active labor. Which of the following findings indicate that the strip should be classified as Category III? (Select all that apply.)Answer →
  243. 243A nurse on a labor and delivery unit is monitoring the fetal heart rate (FHR) pattern of a client in labor. Which of the following findings should the nurse classify as nonreassuring fetal heart rate patterns? (Select All that Apply.)Answer →
  244. 244A nurse is caring for a client who is in active labor and requesting an epidural. Which of the following actions should the nurse take?Answer →
  245. 245A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?Answer →
  246. 246An oxytocin induction was started for a gravid client 6 hours ago. When assessing the fetal heart rate on the electronic fetal monitor, the nurse notes a "U-shaped" pattern occurring with the peak of the contraction. Which intervention should the nurse implement first?Answer →
  247. 247The nurse is monitoring a laboring client who is receiving oxytocin for labor augmentation. The fetal heart tracing shows contractions occurring every 2 minutes, and the fetal heart rate is gradually decreasing after the peak of each contraction and returns to baseline within 40 seconds. Based on this pattern, which finding should the nurse suspect?Answer →
  248. 248A nurse is caring for a client at 20 weeks gestation with twins who just had their anatomy ultrasound. The client tells the nurse that the ultrasound showed baby B in the breech presentation while baby A was vertex and she is worried about not being able to have a vaginal delivery. Which of the following statements by the nurse is the most appropriate?Answer →
  249. 249Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and -3 station. Which of the following actions should the nurse consider during the next contraction?Answer →
  250. 250The nurse performs the second Leopold maneuver by palpating each side of the abdomen. Which information does this provide?Answer →
  251. 251A nurse is caring for a pregnant client at 39 weeks gestation with a history of two prior low transverse cesarean deliveries who is undergoing labor induction with oxytocin. Suddenly, the client reports sharp abdominal pain, and the fetal heart monitor shows variable decelerations followed by bradycardia. The abdomen feels firm and tender on palpation. What is the nurse's most appropriate immediate action?Answer →
  252. 252A nurse is caring for a client who is at risk for shoulder dystocia. Which of the following manifestations indicate that shoulder dystocia is occurring?Answer →
  253. 253A multiparous client in active labor demonstrates cervical dilation progressing from 6 cm to 7 cm over 4 hours. Contractions are regular and strong. What complication does this most likely represent?Answer →
  254. 254A nurse is monitoring the uterine contraction pattern of a client who is in labor. Which of the following characteristics of uterine contractions is most important in relation to fetal oxygenation?Answer →
  255. 255A client in labor is 90% effaced and dilated at 9 cm. Which stage of labor does the nurse document the client is experiencing?Answer →
  256. 256A client is complaining of severe back labor. Which of the following nursing interventions would be most effective?Answer →
  257. 257Which fetal factors can affect the passenger and progress of labor? (Select all that apply.)Answer →
  258. 258A nurse is caring for a client who is experiencing severe pain during active labor. Which of the following medications should the nurse plan to administer and document in the client's medical record?Answer →
  259. 259A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?Answer →
  260. 260While reviewing the fetal monitor tracing of a laboring client at 39 weeks' gestation, the nurse observes a baseline fetal heart rate of 150 beats/min, moderate variability, and accelerations with fetal movement. No decelerations are noted. Which action should the nurse take?Answer →
  261. 261A nurse is caring for a client in early labor. Which finding indicates the onset of true labor?Answer →
  262. 262A nurse on a labor and delivery unit is preparing to asset with several births. Which of the following clients should the nurse recognize as most likely to experience an operative vaginal birth?Answer →
  263. 263A nurse observes variable decelerations on a fetal heart rate monitor during active labor. Which of the following is the most likely cause of these variable decelerations, and what is the priority nursing intervention?Answer →
  264. 264A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate?Answer →
  265. 265Which pelvic type is most favorable for vaginal birth?Answer →
  266. 266A nurse is caring for a client who is receiving an epidural for continuous labor analgesia. Which of the following findings should indicate to the nurse that the treatment is effective?Answer →
  267. 267In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions?Answer →
  268. 268A nurse is educating a new graduate nurse about forceps-assisted deliveries. What statement by the new graduate indicates a need for further education?Answer →
  269. 269A postpartum patient who delivered vaginally is found to have a perineal laceration that extends through the perineal muscles and into the anal sphincter, but does not involve the rectal mucosa. How is this laceration classified?Answer →
  270. 270A woman at 26 weeks' gestation, has just delivered a stillborn baby after a fetal demise. Which of the following nursing actions is appropriate at this time?Answer →
  271. 271A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time?Answer →
  272. 272A nurse is assisting with the care of a client who is in active labor at 39 weeks of gestation. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?Answer →
  273. 273Before applying an internal fetal scalp electrode, the nurse must confirm which condition?Answer →
  274. 274A nurse is caring for a client who is in the active phase of labor. The nurse palpates the umbilical cord during a vaginal examination. Which of the following actions should the nurse take?Answer →
  275. 275During assessment of a laboring client, the nurse notes that the fetal head has reached the level of the ischial spines (0 station). Which mechanism of labor is best described by this finding?Answer →
  276. 276A nurse is caring for a client in labor that is experiencing pain in their back and wants to use non-pharmacologic pain management techniques. Which of the following techniques would be best for the nurse to recommend?Answer →
  277. 277Which presentation is most likely to require cesarean birth if the fetus is viable?Answer →
  278. 278A woman gave birth via normal spontaneous vaginal delivery (NSVD) 10 minutes ago. The nurse observes a gush of blood from the vagina and lengthening of the umbilical cord. What should the nurse conclude?Answer →
  279. 279A nurse performing a vaginal examination palpates the fetal occiput in the front left portion of the client in labor's pelvis. Which of the following entries should the nurse document for the fetal position?Answer →
  280. 280The nurse is assessing a laboring client and notes the following findings: Cervix is 6 cm dilated and 80% effaced. Which of the five P's does this assessment address?Answer →
  281. 281Which clinical finding is most indicative of uterine rupture during labor?Answer →
  282. 282A nurse is determining the strength of contractions for a client in active labor. The client's uterus feels as hard as a forehead during a contraction. How should the nurse document the client's contractions?Answer →
  283. 283A pregnant client calls the healthcare facility stating that she is experiencing labor contractions. Which statement by the client would require the nurse to instruct her to come to the facility immediately?Answer →
  284. 284The nurse suspects a client is experiencing shoulder dystocia during delivery. Which intervention should the nurse implement?Answer →
  285. 285The nurse caring for a client with severe polyhydramnios should monitor for which maternal complication?Answer →
  286. 286During a vaginal examination, the nurse is assessing the fetal station. Which anatomical landmark should the nurse use as a reference point?Answer →
  287. 287A nurse describes a client's contraction pattern as: frequency every 3 minutes and duration of 60 seconds. Which of the following responses corresponds to this description?Answer →
  288. 288The nurse is caring for a client in active labor who is undergoing continuous fetal monitoring. The fetal heart rate (FHR) tracing shows late decelerations with each contraction. Which of the following is the correct interpretation of this finding?Answer →
  289. 289A nurse is assisting with caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should identify that the registered nurse should take?Answer →
  290. 290A nurse repositions the tocodynamometer (TOCO) several times for a client who is in active labor and whose uterine contraction tracing has not been recording accurately. Which of the following steps should the nurse take to obtain an accurate assessment?Answer →
  291. 291The nurse is performing Leopold's maneuver on a 39-week pregnant client. When palpating the fundus, the nurse feels a hard, round fetal part. What should the nurse conclude?Answer →
  292. 292The nurse encourages upright or squatting positions during the second stage of labor because these positions:Answer →
  293. 293A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include?Answer →
  294. 294Which Side effect may be observed upon the accidental intravenous administration Of a local anesthetic? Select all that apply. One, some, or all responses may be correct.Answer →
  295. 295A nurse is assisting in monitoring a client who's receiving oxytocin to induce labor. The nurse would be alert for which maternal adverse reactions? (Select all that apply.)Answer →
  296. 296A nurse is monitoring the progress of a client who is in labor. Which of the following manifestations indicate that the client may be experiencing a uterine rupture?Answer →
  297. 297The nurse explains to a couple that molding of the fetal skull during labor serves which purpose?Answer →
  298. 298The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions?Answer →
  299. 299A laboring client is advised to avoid the supine position during labor, which rationale best explains why the nurse should emphasize this teaching?Answer →
  300. 300Which condition is required before applying an internal fetal scalp electrode?Answer →
  301. 301A nurse who is caring for a client during labor has identified that the fetal spine is lying perpendicular to the client's spine. Which of the following actions should the nurse take?Answer →
  302. 302A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?Answer →
  303. 303A nurse is managing a laboring client with gestational diabetes and fetal macrosomia. During delivery, the fetal head delivers but then retracts back into the perineum (turtle sign). Considering the risk factors and clinical presentation, what is the nurse's priority action to assist in resolving the shoulder dystocia?Answer →
  304. 304Which medication Will the nurse request from the provider when assessing a patient at 39 weeks' gestation 12 hours after administration Of dinoprostone cervical gel and noting the patient is having more than seven uterine contractions every IO minutes?Answer →
  305. 305While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse?Answer →
  306. 306The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. A priority nursing action is to:Answer →
  307. 307A laboring client is not progressing despite adequate contractions. The provider inserts an intrauterine pressure catheter (IUPC). Which statement by the nurse best describes the purpose of the IUPC?Answer →
  308. 308A nurse is caring for a client at 36 weeks of gestation who is experiencing contractions. The client asks why a home birth would not be recommended. Which of the following findings, found in the client's medical record, should the nurse include as reasons for the recommendation of a hospital birth? (Select all that apply.)Answer →
  309. 309A nurse is assessing the fetal heart rate (FHR) of a client at 37 weeks gestation during labor. The monitor shows a baseline FHR of 140 beats per minute with moderate variability and occasional accelerations of 15 beats per minute lasting 15 seconds. What is the best interpretation of this fetal heart rate pattern?Answer →
  310. 310A nurse is caring for a client in the second stage of labor whose provider has recommended an assisted vaginal birth via vacuum extraction due to nonreassuring fetal status. The client asks the nurse, "Why can't I just have a cesarean birth?" Which of the following responses should the nurse make?Answer →
  311. 311A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for?Answer →
  312. 312The charge nurse provided education to a new graduate nurse about the role of a doula during labor. Which statement by the new graduate indicates further education is needed?Answer →
  313. 313A nurse is caring for a client who is at risk for shoulder dystocia. Which of the following manifestations indicate that shoulder dystocia is occurring?Answer →
  314. 314The nurse is caring for a client in labor and notes recurrent variable decelerations on the fetal monitor. What action(s) should the nurse take at this time? Select all that apply.Answer →
  315. 315A laboring patient at 40 weeks is receiving oxytocin. The fetal heart tracing shows a baseline of 170 bpm with minimal variability and recurrent late decelerations. Contractions are occurring every 1.5–2 minutes and lasting 90 seconds. What is the nurse's priority action?Answer →
  316. 316A laboring woman's uterine contractions are being monitored using an external tocodynamometer. The nurse notes contractions occurring every 2 minutes, lasting 70 seconds each, with minimal resting tone between contractions. What is the nurse's most appropriate action?Answer →
  317. 317A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?Answer →
  318. 318A 38-week pregnant client is admitted to the labor and delivery unit with confirmed rupture of membranes (ROM). Her prenatal records indicate: · Positive for Group B Streptococcus (GBS) · Rubella non-immune · No known drug allergies She is experiencing contractions every 4 to 6 minutes. Her vital signs are: · BP: 120/80 mmHg · Temperature: 99.6°F (37.6℃) · Pulse: 95 bpm · Respirations: 18 bpm What is the nurse's priority action?Answer →
  319. 319A nurse is caring for a client in active labor. While performing a cervical exam, the nurse notes that the client is 6cm dilated, 80% effaced, -2 station, and feels the fetal skull. Which of the following would the nurse document as the presenting part?Answer →
  320. 320A woman in labor has just arrived at the labor and delivery unit. Before reporting the client's status to the provider, which assessments should the nurse perform? (Select all that apply.)Answer →
  321. 321A client at 40 weeks' gestation is admitted in active labor and requests to use the birthing tub for pain management. The amniotic fluid is clear, fetal heart rate tracing is category I, and the unit has wireless waterproof fetal monitoring available. The client has a history of precipitous labor. What is the best nursing action?Answer →
  322. 322The MD has ordered amoxicillin suspension 350mg PO for a patient. On hand the nurse has a bottle of amoxicillin labeled 500mg/10mL. Calculate how many ml, the nurse will administer?Answer →
  323. 323A nurse is caring for a client in labor that is in a semi-Fowler's position and is experiencing an increase in pain. Which of the following positions should the nurse offer the client to help reduce their pain? (Select All that Apply)Answer →
  324. 324Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks' gestation?Answer →
  325. 325A woman in labor received an opioid analgesic close to the time of birth. The nurse should assess the newborn for which of the following effects?Answer →
  326. 326What information should the nurse provide to a female who reports being raped?Answer →
  327. 327While observing an electronic fetal monitor, a nurse is assisting the RN in identifying persistent fetal bradycardia, despite intrauterine resuscitation measures of client repositioning and increasing IV fluids. Client vital signs are within normal limits. Which of the following actions should the nurse expect to be taken?Answer →
  328. 328A nurse is preparing to administer an IV fluid bolus of 300 mL 0.9% sodium chloride over one (1) hour, using a microdrip IV tube. The nurse should set the manual IV infusion to deliver how many gtts/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) Example: 10.25 = 10Answer →
  329. 329A nurse is caring for a client in active labor with an epidural in place. Which assessment requires immediate action?Answer →
  330. 330A nurse is preparing a client for epidural anesthesia during labor. Which of the following actions should the nurse take before the procedure? Select all that apply.Answer →
  331. 331It is 1600. A laboring client with an obstetrical history of G1 P0000 who is 3 cm dilated asks the nurse when the dinner tray will be served. The nurse replies:Answer →
  332. 332A nurse is assessing a client in labor who has an indication for epidural anesthesia for pain relief. Which of the following interventions should the nurse take to avoid complications from the epidural block?Answer →
  333. 333A laboring client is about to receive an epidural for pain management. Which nursing action is most important before administering the epidural?Answer →
  334. 334A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear?Answer →
  335. 335A client reports a severe headache that worsens when sitting or standing two days after receiving an epidural. What is the nurse's priority action?Answer →
  336. 336A nurse in a prenatal clinic is teaching a client who has a new prescription for Dinoprostone in gel. Which of the following statements should the nurse include in the teaching?Answer →
  337. 337Which degree of laceration extends through the anal sphincter and rectal mucosa?Answer →
  338. 338The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate?Answer →
  339. 339A primigravida at 41 weeks has been in active labor for 8 hours. Cervical dilation remains at 5 cm despite adequate contractions occurring every 2–3 minutes, lasting 70 seconds. The fetus is in occiput posterior position. Which factor is most likely contributing to this labor dysfunction?Answer →
  340. 340A woman with an obstetrical history of G1 P0000 at 40 weeks gestation enters the labor suite stating that she is in labor. Upon examination, the nurse finds that the woman is 2 cm dilated, 25% effaced, contracting every 12 minutes for 30 seconds. Fetal heart rate is 140 bpm with moderate variability and accelerations. What should the nurse conclude when reporting the findings to the primary healthcare practitioner?Answer →
  341. 341A nurse is caring for a client who had an episiotomy during labor after the fetal heart had shown multiple decelerations. Which of the following explanations should the nurse provide to explain the reason for this procedure?Answer →
  342. 342A nurse is collecting risk assessment data from clients who are in labor. Which of the following factors should the nurse recognize as risk factors for umbilical cord prolapse? (Select All that Apply.)Answer →
  343. 343A new nurse is caring for a client who is in the second stage of labor. The new nurse's preceptor asks when the second stage of labor begin. Which statement by the new nurse is correct?Answer →
  344. 344A laboring client is extremely anxious and tense. She reports fear about the labor process and is unable to relax between contractions. The nurse explains the effects of anxiety on labor. Which statement by the nurse is most accurate?Answer →
  345. 345A nurse is assisting the RN who is caring for a client at 36 weeks of gestation who reports vomiting and diarrhea for the past 48 hr. The client reports no amniotic fluid leakage, bleeding, or uterine contractions. The fetal heart rate baseline is 180/min. Which of the following factors should the nurse anticipate the RN identifying as most likely associated with the fetal heart rate pattern?Answer →
  346. 346A nurse is monitoring a laboring client whose fetal heart rate (FHR) tracing shows a baseline of 130 beats per minute, moderate variability, no late or variable decelerations, and the presence of early decelerations and accelerations. How should the nurse interpret this FHR pattern and what is the appropriate nursing action?Answer →
  347. 347A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?Answer →
  348. 348A client in active labor with an epidural suddenly develops hypotension with a blood pressure of 88/46 mm Hg and a fetal heart rate showing late decelerations. The nurse has already repositioned the client on her side and increased IV fluids. What is the most appropriate next nursing action?Answer →
  349. 349A nurse is providing education to a client who is intrapartum about the Bradley method for pain management. Which of the following statements by the client requires follow up by the nurse?Answer →
  350. 350Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure:Answer →
  351. 351Which definition of an acceleration in the fetal heart rate (FHR) is accurate?Answer →
  352. 352A nurse is caring for a client in labor who has an epidural in place and is on continuous internal monitoring with a fetal scalp electrode and intrauterine pressure catheter. The nurse notes a strong contraction on the monitor and the client reports nausea accompanied by an urgent need to have a bowel movement. Which of the following assessments is the nurse's highest priority?Answer →
  353. 353A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?Answer →
  354. 354A nurse is performing a vaginal examination on a woman in active labor. The presenting part is the fetal head, and it is level with the mother's ischial spines. The nurse documents the fetal station as 0. Based on this finding, which interpretation is most accurate?Answer →
  355. 355A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time?Answer →
  356. 356A nurse is admitting a client who is at 39 weeks of gestation and who states. "My water broke on the way to the hospital." Which of the following actions should the nurse take first?Answer →
  357. 357The nurse is assessing a client in active labor and finds the fetal head at +3 station. What does this finding indicate?Answer →
  358. 358A nurse is monitoring a laboring client with an external electronic fetal monitor and notes the fetal heart rate decelerates after the contraction begins, with the lowest point of the deceleration occurring after the peak of the contraction. What is the nurse's priority action?Answer →
  359. 359A client is experiencing contractions every 3 to 4 minutes lasting for 50 seconds. Her cervix is 2 cm and 50% effaced. While the nurse is assessing her vital signs, the client says, "I think my bag of water just broke." Which of the following should the nurse do first?Answer →
  360. 360The nurse is assessing a client in active labor and finds the fetal head at +3 station. What does this finding indicate?Answer →
  361. 361The nurse is providing education to a new graduate nurse on signs that signify the impending delivery of the placenta. Which statement by the new graduate nurse indicates the need for further education?Answer →
  362. 362Which of the following actions are the nurse's priority? Select the 4 actions that the nurse should take immediately.Answer →
  363. 363A laboring client has a fetus in an occiput posterior (OP) position and the nurse notes molding of the fetal head on assessment. Which nursing intervention best supports safe labor progression and fetal descent?Answer →
  364. 364A nurse is assisting the triage nurse in the labor and delivery unit, who is caring for four clients who have just arrived. Which of the following clients should the nurse expect the RN to see first?Answer →
  365. 365Which is the rationale for the nurse placing a patient receiving an epidural block With ropivacaine in the left lateral position?Answer →
  366. 366A client presents to labor and delivery stating "I am having contractions and I think I am in labor." How should the nurse determine if the client is in true labor?Answer →
  367. 367A nursing student is giving a presentation to their class about uterine rupture. Which of the following points should the student include in the presentation to explain what happens during a uterine rupture?Answer →
  368. 368A client at 38 weeks reports a sudden gush of fluid. Nitrazine test is positive. Fetal heart rate is 140 bpm with moderate variability. What is the most important initial nursing assessment?Answer →
  369. 369A client at term reports irregular abdominal tightening that goes away with rest and hydration. Which finding should the nurse explain?Answer →
  370. 370The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient?Answer →