NUR 335 Intrapartum Nursing Assessment (Answered) Latest
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Course
Nur335
Institution
Nur335
Book
Intrapartum Care
Placental separation
The nurse is preparing to care for a client in labor. The health care provider (HCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse should ensure that which is implemented before the beginning of the infusion?{correct ans} 3. Continuous electronic feta...
The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse
identify as being at the most risk for developing disseminated intravascular coagulation (DIC)?
Select all that apply.
{correct ans}
3.
A gravida II who has just been diagnosed with dead fetus syndrome
5.
A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the
client is beginning the second stage of labor? Select all that apply.
{correct ans}
3.
The cervix is dilated completely.
5.
The spontaneous urge to push is initiated from perineal pressure.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor.
The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is
the most appropriate nursing action?
{correct ans} 1. Administer oxygen via face mask.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39
weeks of gestation. Which assessment finding indicates the need to contact the health care
provider (HCP)?
{correct ans} 2 .Fetal heart rate of 180 beats/minute
The nurse is reviewing the record of a client in the labor room and notes that the health care
provider has documented that the fetal presenting part is at the -1 station. This documented
finding indicates that the fetal presenting part is located at which area?
Click on the image to indicate your answer.
{correct ans} 3
A client arrives at a birthing center in active labor. Following examination, it is determined that
her membranes are still intact and she is at a -2 station. The health care provider prepares to
perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of
the amniotomy? Select all that apply.
{correct ans}
3.
Increased efficiency of
, 5.
The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if
which is noted on the external monitor tracing during a contraction?
{correct ans} 4. Variable decelerations
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After
the client is transferred to the delivery room table, the nurse should place the client in which
position?
{correct ans} 1.Supine position with a wedge under the right hip
The nurse is monitoring a client in active labor and notes that the client is having contractions
every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between
contractions is 100 beats/minute. Which nursing action is most appropriate?
{correct ans} 1. Notify the health care provider (HCP).
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse
notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which
action is most appropriate?
{correct ans} 4. Document the findings and tell the mother that the pattern on the monitor
indicates fetal well-being.
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal
monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next
nursing action?
{correct ans} 2. Assess the baseline fetal heart rate.
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines
that the client understands the signs of true labor if she makes which statement?
{correct ans} 4. "My contractions will increase in duration and intensity."
Which assessment following an amniotomy should be conducted first?
{correct ans} 3. Fetal heart rate pattern
The nurse has been working with a laboring client and notes that she has been pushing effectively
for 1 hour. What is the client's primary physiological need at this time?
{correct ans} 2. Rest between contractions
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's
contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An
internal fetal heart rate monitor is in place. The baseline fetal
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