Obstetrical Nursing – Intrapartum – NCLEX Quiz 2

1. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is:

1 cm above the ischial spine

1 fingerbreadth below the symphysis pubis

1 inch below the coccyx

1 inch below the iliac crest

Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. is measured in centimeters. and is noted as a negative number above the line and a positive number below the line. At -1 station. the fetal presenting part is 1 cm above the ischial spines.

Explanation

Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. is measured in centimeters. and is noted as a negative number above the line and a positive number below the line. At -1 station. the fetal presenting part is 1 cm above the ischial spines.

2. A nurse assists in the vaginal delivery of a newborn infant. After the delivery. the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:

Hematoma

Placenta previa

Uterine atony

Placental separation

As the placenta separates. it settles downward into the lower uterine segment. The umbilical cord lengthens. and a sudden trickle or spurt of blood appears.

Explanation

As the placenta separates. it settles downward into the lower uterine segment. The umbilical cord lengthens. and a sudden trickle or spurt of blood appears.

3. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition?

Medication that will provide sedation

Increased hydration

Oxytocin (Pitocin) infusion

Administration of a tocolytic medication

Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.

Explanation

Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.

4. A client arrives at a birthing center in active labor. Her membranes are still intact. and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure. she will most likely have:

Less pressure on her cervix

Increased efficiency of contractions

Decreased number of contractions

The need for increased maternal blood pressure monitoring

Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.

Explanation

Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.

5. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is:

A form of biofeedback to enhance bearing down efforts during delivery

Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus

The application of pressure to the sacrum to relieve a backache

Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before a transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.

Explanation

Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before a transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.

6. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?

Early decelerations

Variable decelerations

Late decelerations

Short-term variability

Variable decelerations occur if the umbilical cord becomes compressed. thus reducing blood flow between the placenta and the fetus.Option A: Early decelerations result from pressure on the fetal head during a contraction.Option C: Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction.Option D: Short-term variability refers to the beat-to-beat range in the fetal heart rate.

Explanation

Variable decelerations occur if the umbilical cord becomes compressed. thus reducing blood flow between the placenta and the fetus.Option A: Early decelerations result from pressure on the fetal head during a contraction.Option C: Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction.Option D: Short-term variability refers to the beat-to-beat range in the fetal heart rate.

7. A pregnant client is admitted to the labor room. An assessment is performed. and the nurse notes that the client's hemoglobin and hematocrit levels are low. indicating anemia. The nurse determines that the client is at risk for which of the following?

A loud mouth

Low self-esteem

Hemorrhage

Postpartum infections

Anemic women have a greater likelihood of cardiac decompensation during labor. postpartum infection. and poor wound healing. Anemia does not specifically present a risk for hemorrhage.

Explanation

Anemic women have a greater likelihood of cardiac decompensation during labor. postpartum infection. and poor wound healing. Anemia does not specifically present a risk for hemorrhage.

8. A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as:

Exhaustion

Fear of losing control

Involuntary grunting

Valsalva’s maneuver

Pains. helplessness. panicking. and fear of losing control are possible behaviors in the 2nd stage of labor.

Explanation

Pains. helplessness. panicking. and fear of losing control are possible behaviors in the 2nd stage of labor.

9. A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes.

Stop of Pitocin infusion

Perform a vaginal examination

Reposition the client

Check the client’s blood pressure and heart rate

Administer oxygen by face mask at 8 to 10 L/min

If uterine hypertonicity occurs. the nurse immediately will intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution. check maternal BP for hyper or hypotension. position the woman in a side-lying position. and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord.

Explanation

If uterine hypertonicity occurs. the nurse immediately will intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution. check maternal BP for hyper or hypotension. position the woman in a side-lying position. and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord.

Submit

10. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency. duration. and intensity. The priority nursing intervention would be to:

Monitor the Pitocin infusion closely

Provide pain relief measures

Prepare the client for an amniotomy

Promote ambulation every 30 minutes

Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.

Explanation

Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.