Question 1

The laboring patient has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100-105. Which nursing action is most important?

Accepted Answer

A)  Change the mother's position from Fowler's to left lateral.
B)  Insert a Foley catheter with the assistance of another nurse.
C)  Notify the surgical team of an impending cesarean.
D)  Decrease the IV of lactated Ringer's solution to 50 ml/hour.

Question 2

The multiparous patient at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold's maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What physician order is most important?

Accepted Answer

A)  Artificially rupture membranes.
B)  Apply internal fetal scalp electrode.
C)  Monitor maternal blood pressure every 15 minutes.
D)  Alert the surgical team of urgent cesarean.

Question 3

The primiparous patient is at 42 weeks' gestation. What order should the nurse question?

Accepted Answer

A)  Obtain biophysical profile today.
B)  Begin nonstress test now.
C)  Schedule labor induction for tomorrow.
D)  Return to the clinic in one week.

Question 4

The patient gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. The nurse should prepare to:

Accepted Answer

A)  Start an IV of lactated Ringer's.
B)  Apply anti-embolism stockings.
C)  Bottle-feed the infant.
D)  Send the placenta to pathology.

Question 5

The multiparous patient at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention?

Accepted Answer

A)  Temperature 99.0°F
B)  Platelet count 210,000/cmm
C)  Fibrinogen level 50 mg/dL
D)  Family refusing fetal autopsy C

Question 6

The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?

Accepted Answer

A)  Assess the odor of the amniotic fluid.
B)  Perform Leopold's maneuver.
C)  Obtain an order for pain medication.
D)  Complete a sterile vaginal exam. D

Question 7

The patient has delivered a 4,200g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The patient asks the nurse where she tore. Which response is best? "The episiotomy extended and tore:

Accepted Answer

A)  "Through your rectal mucosa."
B)  "Up near your urethra."
C)  "Into the muscle layer."
D)  "Through your rectal sphincter."

Question 8

The charge nurse is reviewing charting on patients in the maternal-child triage unit. Which entry requires immediate intervention?

Accepted Answer

A)  Primip at 24 weeks diagnosed with polyhydramnios: "Patient reporting shortness of breath."
B)  Multip at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis."
C)  Primip at 41 weeks: "Patient reports leaking clear fluid from her vagina for seven hours."
D)  Multip at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."

Question 9

The nurse is making patient assignments for the next shift. Which patient is most likely to experience a complicated labor pattern?

Accepted Answer

A)  34-year-old gravida 6 at 39 weeks' gestation with twins
B)  22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes
C)  30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 pounds, 8 ounces
D)  43-year-old gravida 2 at 37 weeks' gestation with hypertension

Question 10

Two hours ago, the 39-weeks'-gestation patient was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every five minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every three minutes with 40-50 seconds' duration with intensity of 40 mmHg. The priority intervention would be:

Accepted Answer

A)  Begin oxytocin after assessing for CPD.
B)  Give Terbutaline to stop the preterm labor.
C)  Start oxygen at 8 L/min.
D)  Have anesthesia give the patient an epidural. A

Question 11

The nurse is caring for a laboring patient with known cephalopelvic disproportion (CPD) . The woman develops tachysystolic labor patterns. Which possible course of treatment should the nurse anticipate?

Accepted Answer

A)  Oxytocin administration
B)  Cesarean section
C)  Nipple stimulation
D)  Amniotomy

Question 12

The nurse should anticipate the labor pattern for a fetal occiput posterior position to be:

Accepted Answer

A)  Shorter than average during the latent phase.
B)  Prolonged with regard of the overall length of labor.
C)  Rapid during transition.
D)  Precipitous.

Question 13

A patient who sustained a difficult, lengthy labor and delivery is conversing with the nurse. Suddenly, the patient complains of chest pain and appears dyspneic. She is cyanotic and tachycardic, and her blood pressure has decreased to 78/36. What condition should the nurse suspect is developing?

Accepted Answer

A)  Placenta accreta
B)  Infection
C)  Hypertensive crisis
D)  Amniotic fluid embolus

Question 14

A 20-year-old woman who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the patient's labor?

Accepted Answer

A)  Cephalopelvic disproportion (CP
D)  
B)  Prolapsed cord
C)  Placenta accreta
D)  Occiput anterior (O
A)   fetal position

Question 15

The patient has undergone an ultrasound, which estimated fetal weight at 4,500 g (9 pounds, 14 ounces) . Which statement indicates that additional teaching is needed? "Because my baby is big:

Accepted Answer

A)  "I am at risk for excessive bleeding after delivery."
B)  "His blood sugars could be high after he is born."
C)  "My perineum could experience trauma during the birth."
D)  "His shoulders could get stuck and a collar bone broken."

Exam 22: Childbirth at Risk: Labor-Related Complications

The laboring patient has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100-105. Which nursing action is most important?

Correct Answer
verified

The multiparous patient at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold's maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What physician order is most important?

Correct Answer
verified

The primiparous patient is at 42 weeks' gestation. What order should the nurse question?

Correct Answer
verified

The patient gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. The nurse should prepare to:

Correct Answer
verified

The multiparous patient at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention?

Correct Answer
verified
C

The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?

Correct Answer
verified
D

The patient has delivered a 4,200g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The patient asks the nurse where she tore. Which response is best? "The episiotomy extended and tore:

Correct Answer
verified

The charge nurse is reviewing charting on patients in the maternal-child triage unit. Which entry requires immediate intervention?

Correct Answer
verified

The nurse is making patient assignments for the next shift. Which patient is most likely to experience a complicated labor pattern?

Correct Answer
verified

Correct Answer
verified
A

The nurse is caring for a laboring patient with known cephalopelvic disproportion (CPD) . The woman develops tachysystolic labor patterns. Which possible course of treatment should the nurse anticipate?

Correct Answer
verified

The nurse should anticipate the labor pattern for a fetal occiput posterior position to be:

Correct Answer
verified

A patient who sustained a difficult, lengthy labor and delivery is conversing with the nurse. Suddenly, the patient complains of chest pain and appears dyspneic. She is cyanotic and tachycardic, and her blood pressure has decreased to 78/36. What condition should the nurse suspect is developing?

Correct Answer
verified

Correct Answer
verified

The patient has undergone an ultrasound, which estimated fetal weight at 4,500 g (9 pounds, 14 ounces) . Which statement indicates that additional teaching is needed? "Because my baby is big:

Correct Answer
verified

Exam 22: Childbirth at Risk: Labor-Related Complications

The laboring patient has experienced spontaneous rupture of membranes. The fluid is meconium-stained. The fetal heart tones are 100-105. Which nursing action is most important?

Correct AnswerverifiedShow Answer

The multiparous patient at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold's maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What physician order is most important?

Correct AnswerverifiedShow Answer

The primiparous patient is at 42 weeks' gestation. What order should the nurse question?

Correct AnswerverifiedShow Answer

The patient gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. The nurse should prepare to:

Correct AnswerverifiedShow Answer

The multiparous patient at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention?

Correct AnswerverifiedC

The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?

Correct AnswerverifiedD

The patient has delivered a 4,200g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The patient asks the nurse where she tore. Which response is best? "The episiotomy extended and tore:

Correct AnswerverifiedShow Answer

The charge nurse is reviewing charting on patients in the maternal-child triage unit. Which entry requires immediate intervention?

Correct AnswerverifiedShow Answer

The nurse is making patient assignments for the next shift. Which patient is most likely to experience a complicated labor pattern?

Correct AnswerverifiedShow Answer

Correct AnswerverifiedA

The nurse is caring for a laboring patient with known cephalopelvic disproportion (CPD) . The woman develops tachysystolic labor patterns. Which possible course of treatment should the nurse anticipate?

Correct AnswerverifiedShow Answer

The nurse should anticipate the labor pattern for a fetal occiput posterior position to be:

Correct AnswerverifiedShow Answer

A patient who sustained a difficult, lengthy labor and delivery is conversing with the nurse. Suddenly, the patient complains of chest pain and appears dyspneic. She is cyanotic and tachycardic, and her blood pressure has decreased to 78/36. What condition should the nurse suspect is developing?

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

The patient has undergone an ultrasound, which estimated fetal weight at 4,500 g (9 pounds, 14 ounces) . Which statement indicates that additional teaching is needed? "Because my baby is big:

Correct AnswerverifiedShow Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
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Correct Answer
verified

Correct Answer
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C

Correct Answer
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D

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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A

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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