Intrapartum

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1. The nurse in a maternity unit is reviewing the clients' 3.

records. Which clients should the nurse identify as A gravida II who
being at the most risk for developing disseminated has just been diag-
intravascular coagulation (DIC)? Select all that apply. nosed with dead
fetus syndrome

5.
A primigravida
at 29 weeks
of gestation who
was recently diag-
nosed with severe
preeclampsia

2. The nurse is caring for a client in labor. Which assess- 3.

ment findings indicate to the nurse that the client is The cervix is dilat-
beginning the second stage of labor? Select all that ed completely.
apply.
5.
The spontaneous
urge to push is
initiated from per-
ineal pressure.

3. The nurse in the labor room is caring for a client in the 1. Administer oxy-
active stage of the first phase of labor. The nurse is gen via face mask.
assessing the fetal patterns and notes a late decelera-
tion on the monitor strip. What is the most appropriate
nursing action?

4. The nurse is performing an assessment of a client 2 .Fetal heart

who is scheduled for a cesarean delivery at 39 weeks rate of 180
of gestation. Which assessment finding indicates the beats/minute
need to contact the health care provider (HCP)?

5. The nurse is reviewing the record of a client in the 3

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
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fetal presenting part is located at which area? Click
on the image to indicate your answer.

6. A client arrives at a birthing center in active labor. 3.

Following examination, it is determined that her mem- Increased efficien-
branes are still intact and she is at a -2 station. The cy of contractions
health care provider prepares to perform an amnioto-
my. What will the nurse relay to the client as the most 5.
likely outcomes of the amniotomy? Select all that ap- The need for fre-
ply. quent fetal heart
rate monitoring to
detect the pres-
ence of a pro-
lapsed cord

7. The nurse is monitoring a client in labor. The nurse 4. Variable decel-

suspects umbilical cord compression if which is not- erations
ed on the external monitor tracing during a contrac-
tion?

8. A client in labor is transported to the delivery room 1.Supine position

and prepared for a cesarean delivery. After the client with a wedge un-
is transferred to the delivery room table, the nurse der the right hip
should place the client in which position?

9. The nurse is monitoring a client in active labor and 1. Notify the health
notes that the client is having contractions every care provider
3 minutes that last 45 seconds. The nurse notes (HCP).
that the fetal heart rate between contractions is 100
beats/minute. Which nursing action is most appropri-
ate?

10. The nurse is caring for a client in labor and is monitor- 4. Document the
ing the fetal heart rate patterns. The nurse notes the findings and tell
presence of episodic accelerations on the electronic the mother that
fetal monitor tracing. Which action is most appropri- the pattern on the
ate? monitor indicates
fetal well-being.

11.
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The nurse is admitting a pregnant client to the labor 2. Assess the
room and attaches an external electronic fetal monitor baseline fetal
to the client's abdomen. After attachment of the elec- heart rate.
tronic fetal monitor, what is the next nursing action?

12. The nurse is reviewing true and false labor signs with 4. "My contrac-
a multiparous client. The nurse determines that the tions will increase
client understands the signs of true labor if she makes in duration and in-
which statement? tensity."

13. Which assessment following an amniotomy should be 3. Fetal heart rate

conducted first? pattern

14. The nurse has been working with a laboring client and 2. Rest between
notes that she has been pushing effectively for 1 hour. contractions
What is the client's primary physiological need at this
time?

15. The nurse is assisting a client undergoing induction 2. Discontinue the

of labor at 41 weeks of gestation. The client's contrac- infusion of oxy-
tions are moderate and occurring every 2 to 3 minutes, tocin.
with a duration of 60 seconds. An internal fetal heart
rate monitor is in place. The baseline fetal heart rate
has been 120 to 122 beats/minute for the past hour.
What is the priority nursing action?

16. The nurse is assessing a pregnant client in the sec- 2. Uterine tender-
ond trimester of pregnancy who was admitted to the ness
maternity unit with a suspected diagnosis of abrup-
tio placentae. Which assessment finding should the
nurse expect to note if this condition is present?

17. The maternity nurse is preparing for the admission 2. Obtain equip-
of a client in the third trimester of pregnancy who is ment for a manu-
experiencing vaginal bleeding and has a suspected al pelvic examina-
diagnosis of placenta previa. The nurse reviews the tion.
health care provider's prescriptions and should ques-
tion which prescription?

18.
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The nurse is monitoring a client who is in the active 1.
stage of labor. The nurse documents that the client Age 54
is experiencing labor dystocia. The nurse determines
that which risk factors in the client's history placed 2.
her at risk for this complication? Select all that apply. Body mass index
of 28

3.
Previous difficulty
with fertility

19. The nurse in a birthing room is monitoring a client 4. Persistent non-

with dysfunctional labor for signs of fetal or maternal reassuring fetal
compromise. Which assessment finding should alert heart rate
the nurse to a compromise?

20. The nurse in a labor room is preparing to care for a 1. Provide pain re-
client with hypertonic uterine contractions. The nurse lief measures.
is told that the client is experiencing uncoordinated
contractions that are erratic in their frequency, dura-
tion, and intensity. What is the priority nursing action?

21. The nurse is reviewing the health care provider's 3. Perform a vagi-
(HCP's) prescriptions for a client admitted for prema- nal examination
ture rupture of the membranes. Gestational age of the every shift.
fetus is determined to be 37 weeks. Which prescrip-
tion should the nurse question?

22. The nurse has created a plan of care for a client experi- 2. Monitoring the
encing dystocia and includes several nursing actions fetal heart rate
in the plan of care. What is the priority nursing action?

23. The nurse is performing an assessment on a client 4.

diagnosed with placenta previa. Which assessment Bright red vaginal
findings should the nurse expect to note? Select all bleeding
that apply.
5.
Soft, relaxed, non-
tender uterus

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6.
Fundal height may
be greater than ex-
pected for gesta-
tional age

24. The nurse is providing emergency measures to a 1. The client's fear

client in labor who has been diagnosed with a pro-
lapsed cord. The mother becomes anxious and fright-
ened and says to the nurse, "Why are all of these
people in here? Is my baby going to be all right?"
Which client problem is most appropriate to address
at this time?

25. The maternity nurse is caring for a client with abrup- 1.

tio placentae and is monitoring her for disseminat- Petechiae
ed intravascular coagulation (DIC). Which assessment
findings are most likely associated with disseminated 2.
intravascular coagulation? Select all that apply. Hematuria

4.
Prolonged clotting
times

5.
Oozing from injec-
tion sites

26. The nurse in a labor room is assisting with the vaginal 1. Forceps delivery
delivery of a newborn infant. The nurse should moni-
tor the client closely for the risk of uterine rupture if
which occurred?

27. The nurse is caring for a client who is experiencing 2. Breathe rapidly.
a precipitous labor and is waiting for the health care
provider to arrive. When the infant's head crowns,
what instruction should the nurse give the client?

28. 3. "It is light

stroking of the ab-
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The nurse explains the purpose of effleurage to a domen to facili-
client in early labor. Which statement should the nurse tate relaxation dur-
include in the explanation? ing labor and pro-
vide tactile stimu-
lation to the fetus."

29. A client in labor is dilated 10 cm. At this point in the 2. Every 15 min-
labor process, at least how often should the nurse utes
assess and document the fetal heart rate?

30. The nurse is caring for a client in labor and prepares 3. Palpating the
to auscultate the fetal heart rate (FHR) by using a maternal radial
Doppler ultrasound device. Which action should the pulse while listen-
nurse take to determine fetal heart sounds accurate- ing to the FHR
ly?

31. The nurse is caring for a client in labor who is receiv- 2. A fetal heart rate
ing oxytocin by intravenous infusion to stimulate uter- of 90 beats/minute
ine contractions. Which assessment finding should
indicate to the nurse that the infusion needs to be
discontinued?

32. The nurse is preparing to care for a client in labor. The 3. Continuous
health care provider has prescribed an intravenous electronic fetal
(IV) infusion of oxytocin. The nurse ensures that which monitoring
intervention is implemented before initiating the infu-
sion?

33. The nurse assists in the vaginal delivery of a newborn 4. Placental sepa-
infant. After the delivery, the nurse observes the um- ration
bilical cord lengthen and a spurt of blood from the
vagina. The nurse documents these observations as
signs of which condition?

34. During the intrapartum period, the nurse is caring for a 2. Prevent dehy-
client with sickle cell disease. The nurse ensures that dration and hypox-
the client receives adequate intravenous fluid intake emia.
and oxygen consumption to achieve which outcome?

35.
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A client with a 38-week twin gestation is admitted to 1. Measure fundal
a birthing center in early labor. One of the fetuses height.
is a breech presentation. Which intervention is least
appropriate in planning the nursing care of this client?

36. The nurse prepares a plan of care for the client with 2. Clear and main-
preeclampsia and documents that if the client pro- tain an open air-
gresses from preeclampsia to eclampsia, the nurse way.
should take which first action?

37. A prenatal client with vaginal bleeding is being admit- 4. Painless vaginal
ted to the labor unit. The labor room nurse is perform- bleeding
ing the admission assessment and should suspect a
diagnosis of placenta previa if which finding is noted?

38. A prenatal client with severe abdominal pain is admit- 3.

ted to the maternity unit. The nurse is monitoring the Increase in fundal
client closely because concealed bleeding is suspect- height
ed. Which assessment findings indicate the presence
of concealed bleeding? Select all that apply. 4.
Hard, boardlike
abdomen

5.
Persistent abdomi-
nal pain

39. The nurse is caring for a client during the second 1. Turn the client
stage of labor. On assessment, the nurse notes a onto her side and
slowing of the fetal heart rate and a loss of variability. give oxygen by
Which is the initial nursing action? face mask at 8 to
10 L/min.

40. An amniotomy is performed on a client in labor. On the 4. Pale straw in

amniotic fluid examination, the delivery room nurse color, with flecks of
should identify which findings as normal? vernix

41. A labor room nurse is performing an assessment on 2. Continue to

a client in labor and notes that the fetal heart rate monitor the client.
(FHR) is 158 beats/minute and regular. The client's
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contractions are every 5 minutes, with a duration of
40 seconds and of moderate intensity. On the basis
of these assessment findings, what is the appropriate
nursing action?

42. The nurse is creating a plan of care for a pregnant 1.

client with a diagnosis of severe preeclampsia. Which Keep the room
nursing actions should be included in the care plan semi-dark.
for this client? Select all that apply.
2.
Initiate seizure
precautions.

3.
Pad the side rails
of the bed.

4.
Avoid environmen-
tal stimulation.

43. The labor room nurse assists with the administration 4. Monitoring the
of a lumbar epidural block. How should the nurse mother's blood
check for the major side effect associated with this pressure
type of regional anesthesia?

44. The nurse assists the health care provider to perform 1. Assess the fetal
an amniotomy on a client in labor. Which is the priority heart rate.
nursing action after this procedure?

45. The goal for a woman with partial premature separa- 2. Moderate vari-
tion of the placenta is: "The woman will not exhibit ability present
signs of fetal distress." Which outcome, document-
ed by the nurse, indicates that this goal has been
achieved?

46. The nurse is assessing the deep tendon reflexes of a 1

client with severe preeclampsia who is receiving intra-
venous magnesium sulfate. The nurse should perform

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which procedure to assess the brachioradialis reflex?
Click on the image to indicate your answer.

47. The nurse is caring for a client in active labor. Which 3. Encourage an
nursing intervention would be the best method to upright or side-ly-
prevent fetal heart rate (FHR) decelerations? ing maternal posi-
tion.

48. The nurse is administering magnesium sulfate to a 1. Assess for signs

client for preeclampsia at 34 weeks' gestation. What and symptoms of
is the priority nursing action for this client? labor.

49. The nurse is preparing to administer an analgesic to a 3. Butorphanol tar-

client in labor. Which analgesic is contraindicated for trate
a client who has a history of opioid dependency?

50. The nurse in a delivery room is assessing a client im- 4. Complaints of

mediately after delivery of the placenta. Which mater- severe abdominal
nal observation could indicate uterine inversion and pain
require immediate intervention?

51. The nurse is caring for a client in the transition phase 4. Fear of losing
of the first stage of labor. The client is experiencing control
uterine contractions every 2 minutes and she cries out
in pain with each contraction. What is the nurse's best
interpretation of this client's behavior?

52. Fetal distress is occurring with a woman in labor. As 4. Administer oxy-

the nurse prepares her for a cesarean birth, what other gen at 8 to 10
intervention should the nurse implement? L/min via face
mask.

53. A pregnant 39-week-gestation gravida 1, para 0 client 3. Call the health

arrives on the labor and delivery unit with signs care provider
and symptoms of active labor. The nurse reviews the (HCP) to ob-
client's prenatal record and discovers that she has tain a prescription
had a positive group B streptococcus (GBS) laborato- for intravenous an-
ry report during her prenatal course. After performing tibiotic prophylaxis
a cervical exam, the nurse confirms that the cervix is (IAP).

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dilated 6 cm and 90% effaced. Which should be the
nurse's first action?

54. A pregnant 39-week-gestation client arrives at the la- 3. Explain to the

bor and delivery unit in active labor. On confirmation client why a ce-
of labor, the client reports a history of herpes simplex sarean delivery is
virus (HSV) to the nurse, who notes the presence of necessary.
lesions on inspection of the client's perineum. Which
should be the nurse's initial action?

55. The nurse is caring for a client in labor and notes 3.

that minimal variability is present on a fetal heart rate Tachycardia
(FHR) monitor strip. Which conditions are most likely
associated with minimal variability? Select all that 4.
apply. Fetal hypoxia

5.
Metabolic
acidemia

6.
Congenital anom-
alies

56. After the spontaneous rupture of a laboring woman's 2. Assess the vagi-
membranes, the fetal heart rate drops to 85 na and cervix with
beats/minute. Which should be the nurse's priority a gloved hand.
action?

57. On assessment of the fetal heart rate (FHR) of a la- 2. Periodic, early
boring woman, the nurse discovers decelerations that decelerations that
have a gradual onset, last longer than 30 seconds, and indicate fetal head
return to the baseline rate with the completion of each compression
contraction. The nurse plans care, knowing that this
identifies which category of decelerations?

58. Shortly after receiving epidural anesthesia, a laboring 4.

woman's blood pressure drops to 95/43 mm Hg. Which Turn the woman to
immediate actions should the nurse take? Select all a lateral position.
that apply.
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5.
Increase the rate
of the intravenous
infusion.

6.
Administer oxygen
by face mask at 10
L/minute.

59. The nurse is administering an intravenous analgesic 3."Because the

to a laboring woman. The woman inquires as to why uterine blood ves-
the nurse is waiting for a contraction to begin before sels constrict dur-
she infuses the medication into the intravenous line. ing a contraction,
Which is the nurse's most appropriate response? the fetus will be
less affected by
the medication."

60. On March 10, the nurse performed an initial assess- 1. The client
ment on a client admitted to the labor and delivery is possibly in
unit for "rule out labor." The client has not received preterm labor.
prenatal care but is certain that the first day of her last
menstrual period (LMP) was July 7 the previous year.
The nurse plans care based on which interpretation?

61. The nurse is assigned to care for a client with hy- 1. Oxytocin infu-
potonic uterine dysfunction and signs of a slowing sion
labor. The nurse is reviewing the health care provider's
prescriptions and should expect to note which pre-
scribed treatment for this condition?

62. A woman in active labor has requested a regional 1. Palpate the

anesthetic. She is currently 5 cm dilated. The health bladder at frequent
care provider has prescribed an epidural block. Which intervals.
nursing intervention should be implemented after the
epidural block has been placed?

63. The nurse in the labor room is caring for a client who 4. Document the
is in the first stage of labor. On assessing the fetal findings and con-
patterns, the nurse notes an early deceleration of the
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fetal heart rate (FHR) on the monitor strip. Based on tinue to monitor fe-
this finding, which is the appropriate nursing action? tal patterns.

64. The nurse is caring for a client who is receiving oxy- 1. Stop the oxy-
tocin for induction of labor and notes a nonreassuring tocin infusion.
fetal heart rate (FHR) pattern on the fetal monitor. On
the basis of this finding, the nurse should take which
action first?

65. Which statement, if made by the laboring client, most 1. "I feel like I need
likely indicates that the client is in the second stage to push."
of labor?

66. The nurse is caring for a client in the active stage of 1. Administering
labor. The nurse notes that the fetal pattern shows a oxygen via face
late deceleration on the monitor strip. Based on this mask
finding, the nurse should prepare for which appropri-
ate nursing action?

67. A client in labor is receiving oxytocin by intravenous 2. A fetal heart rate

infusion to stimulate uterine contractions. Which find- of 180 beats/min
ing indicates that the rate of infusion needs to be
decreased?

68. The nurse is monitoring a client in labor whose mem- 1. Determine the
branes ruptured spontaneously. What is the initial fetal heart rate.
nursing action?

69. The nurse assists in the vaginal delivery of a newborn. 4. Placental sepa-
Following the delivery, the nurse observes the umbili- ration
cal cord lengthen and a spurt of blood from the vagina.
The nurse should document these observations as
signs of which condition?

70. The nurse is preparing to care for a client in labor. The 3. Continuous
health care provider (HCP) has prescribed an intra- electronic fetal
venous (IV) infusion of oxytocin. The nurse should en- monitoring
sure that which is implemented before the beginning
of the infusion?

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71. The nurse is assisting in the care of a client in labor 1.
who is having an amniotomy performed. The nurse Clear, dark amber
should report which abnormal findings to the health amniotic fluid
care provider (HCP)? Select all that apply.
3.
Light green amni-
otic fluid with no
odor

4.
Thick white amni-
otic fluid with no
odor

72. The nurse is creating a plan of care for a client ex- 1. Monitoring fetal
periencing dystocia and includes several nursing in- status
terventions in the plan. The nurse prioritizes the plan
and selects which nursing intervention as the highest
priority?

73. The nurse is monitoring a client with dysfunctional 2. The passage of

labor for signs of fetal or maternal compromise. Which meconium
finding should alert the nurse to a compromise?

74. The nurse is preparing to care for a client with hyper- 1. Provide pain re-
tonic labor. The nurse is told that the client is experi- lief measures.
encing uncoordinated contractions that are erratic in
their frequency, duration, and intensity. Which is the
priority nursing intervention?

75. The nurse performs a vaginal assessment on a preg- 2. Place the client
nant client in labor. On assessment, the nurse notes in Trendelenburg's
the presence of the umbilical cord protruding from the position.
vagina. Which is the initial nursing action?

76. The nurse is caring for a client during the second 1. Turn the client
stage of labor. On assessment, the nurse notes a slow- on her side and
ing of the fetal heart rate and a loss of variability. What administer oxygen
is the initial nursing action? by face mask at 8
to 10 L/min.
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77. An ultrasound is performed on a client with suspect- 1. Delivery of the

ed abruptio placentae, and the results indicate that fetus
a placental abruption is present. Which intervention
should the nurse prepare the client for?

78. The nurse is monitoring a client who is in the active 1. Hypotonic

phase of labor. The client has been experiencing con-
tractions that are short, irregular, and weak. Which
type of labor dystocia should the nurse document that
the client is experiencing?

79. The nurse has collected the following data on a client 2. Continue to
in labor. The fetal heart rate (FHR) is 154 beats/min and monitor the client.
is regular, and contractions have moderate intensity,
occur every 5 minutes, and have a duration of 35 sec-
onds. Using this information, what is the appropriate
action for the nurse to take?

80. A pregnant client admitted to the labor room arrived 4. Wrap the cord
with a fetal heart rate (FHR) of 94 beats/minute and the loosely in a sterile
umbilical cord protruding from the vagina. The client towel soaked with
tells the nurse that her "water broke" before coming to warm, sterile nor-
the hospital. What is the appropriate nursing action? mal saline.

81. The purpose of a vaginal examination for a client in 1.

labor is to specifically assess the status of which Station
findings? Select all that apply.
2.
Dilation

3.
Effacement

82. The nurse is collecting data from a pregnant client in 1.

the second trimester of pregnancy who was admit- Uterine tender-
ted to the maternity unit with a suspected diagnosis ness
of abruptio placentae. Which findings are associated
with abruptio placentae? Select all that apply. 2.
Acute abdominal
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pain

3.
A hard, "boardlike"
abdomen

5.
Increased uterine
resting tone on fe-
tal monitoring

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