which maternal conditions should be considered an unfavorable condition for the application of internal monitoring devices?
Maternal HIV
the nurse is reviewing the electronic monitor tracing of a client who is in active labor. the nurse knows that a fetus receives more oxygen when which of the following appears on the tracing?
relaxation between uterine contractions
the nurse is concerned that a patients uterine activity is too intense and that her obesity is preventing accurate assessment of contractions. based on this information, which action should the nurse take?
obtain an order from the health care provider for an intrauterine pressure catheter
if the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen?
right lower
in which situation would the baseline fetal heart rate of 160 to 170 bpm be considered a normal finding?
the fetus is at 30 weeks of gestation
when the mothers membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?
variable decelerations
the fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. the best interpretation of this is that the fetus is showing
a reassuring response, an expected response
which of the following is the priority intervention for a supine patient whose monitor strip shows deceleration that begin after the peak of the contraction and return to the baseline after the contraction ends
reposition to left side lying position
decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. the nurse should
maintain the normal assessment routine
a nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. the nurse recognizes the adverse effect of this contraction pattern is
reduced fetal oxygen supply
the nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 bpm below baseline and returns to the baseline well after the completion of the patients contractions. how will the nurse document these findings?
late decelerations
a patient at 41 weeks gestation is undergoing an induction of labor with an IV administration of oxytocin (pitocin). the fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. what is the nurses priority action?
stop the infusion of pitocin
the nurse admits a laboring patient at term. on review of the prenatal record, the patients pregnancy has been unremarkable and she is considered low risk. in planning the patients care, at what interval will the nurse intermittently auscultate the fetal heart rate during the 1st stage of labor? during stage 2?
every 30 minutes stage 1, every 15 minutes stage 2
the nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip. which is the most appropriate nursing action?
administer oxygen with a face mask at 8 to 10 L/min
the nurse is preparing to perform leopolds maneuvers. please select the rationale for the consistent use of these maneuvers by obstetric providers?
to determine the best location to assess the fetal heart rate
a primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. the fetal heart rate has been normal. contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. cervical dilation is 1 to 2 cm and uneffaced. membranes are intact. the nurse should expect the patient to be
discharged home to await the onset of true labor
which nursing assessment indicates that a patient who is in the 2nd stage of labor is almost ready to give birth?
the vulva bulges and encircles the fetal head
a 25 year old primigravida client is in the 1st stage of labor. she and her husband have been holding hands and breathing together through each contraction. suddenly the client pushes her husbands hand away and shouts, "dont touch me!" this behavior is most likely
common during the transition phase of labor
at 1 minute after birth, the nurse assesses the newborn to assign an apgar score. the apical heart rate is 110 bpm, and the infant is crying vigourously with the limbs flexed. the infants trunk is pinkm but the hands and feet are blue. the apgar score for this infant is
9
the nurse thoroughly dries the infant immediately after birth primarily to
reduce heat loss from evaporation
the nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high pitched tones. based on this observation, which action should the nurse take?
document this evidence of normal early maternal infant attachment behavior
the labor nurse is reviewing the cardinal maneuvers with a group of nursing students. which maneuver will immediately follow the birth of the babys head
restitution
the nurse is explaining the technique of internal version to a nursing orientee. which statement best describes the technique of internal version?
manipulation of the 2nd twin from a transverse lie to a breech presentation during vaginal birth
for which patient should the oxytocin (pitocin) infusion be discontinued immediately?
a patient in active labor with contractions every 1-2 minutes lasting 80-90 seconds each
while assisting with a vacuum extraction birth, which alteration should the nurse immediately report to the obstetric provider?
persistent fetal bradycardia below 100 bpm
which technique is most effective for the patient with persistent occiput posterior position?
rocking the pelvis back and forth while on hands and knees
which technique is least effective for the woman with persistent occiput posterior position?
lie supine and relax
which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?
a multipara patient at 39 weeks of gestation who is expecting twins
which nursing action should be initiated first when there is evidence of prolapsed cord?
reposition the woman with her hips higher than her head
what factor found in maternal history should alert the nurse to the potential for a prolapsed umbilical cord?
presenting part at station -3
the fetus in a breech presentation is often born by cesarean delivery because
compression of the umbilical cord is more likely
a woman who is 32 weeks pregnant telephones the nurse at her ob office and complains of constant backache. she asks what pain reliever is safe for her to take. the best nursing response is
you should come into the office and let the doctor check you
what is the priority nursing assessments for a woman receiving tocolytic therapy with terbutaline
fetal heart rate, maternal pulse, and blood pressure
a pregnant client who has had a prior obstetric history of preterm labors is pregnant with her 3rd child. the physician has ordered an fetal fibronectin test. which instructions should be given to the client related to this clinical test?
client should refrain from sexual activity prior to testing
a labor client has been diagnosed with cephalopelvic disproportion following attempts at pushing for 2 hours with no progress. based on this information, what birth method is available?
cesarean section
which assessment finding indicates a complication in the patient attempting a vaginal birth after cesarean?
complaint of paint between the scapulae
a pregnant woman develops hypertension. the nurse monitors the patients blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with which complication?
placental insufficiency, reduced placental blood flow
if the patients WBC count is 25,000 on her 2nd postpartum day which action should the nurse take?
document the finding
a postpartum patient asks, will these stretch marks ever go away, which is the nurses best response
they will fade to silvery lines but wont disappear completely
the nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. which amount of lochia consist of a light amount
2.5 to 10cm, 1 to 4 inch
the nurse has completed a postpartum assessment on a client who delivered an hour ago. which amount of lochia consists of a scant amount
less than 1 inch stain on the peripad
an example of binding (claiming in) during the postpartum period is
new mother telling her friends all about her labor and birth experience
which medication could potentially cause hyperstimulation of the uterus during labor?
oxytocin, misoprostol, dinoprostone, methylergonovine
a laboring client is 10 cm dilated but does not feel the urge to push. the nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following?
less maternal fatigue, less birth canal injuries, decreased pushing time
the nurse is monitoring a client in the active stage of labor. which conditions associated with fetal compromise should the nurse monitor?
maternal hypotension, meconium stained amniotic fluid, maternal fever 100.4 or higher, incomplete uterine relaxation between contractions
the nurse is caring for a client in the 4th stage of labor. which assessment findings should the nurse identify as a potential complication
soft boggy uterus, high uterine fundus displaced to the right, intense vaginal pain unrelieved by analgesics
which vaccinations are indicated for the postpartum client if she does not have immunity?
pertussis, rubella, diphtheria tetanus (Tdap), varicella