Labor and Birth Complications II

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

• Stimulate the labor process.

• Prevent dehydration and hypoxemia.

• Avoid the necessity of a cesarean delivery.

• Eliminate the need for analgesic administration.

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

• Measure fundal height.

• Attach electronic fetal monitoring.

• Prepare the client for a possible cesarean section.

• Visually examine the perineum and vaginal opening.

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

• Measure fundal height.

• Attach electronic fetal monitoring.

• Prepare the client for a possible cesarean section.

• Visually examine the perineum and vaginal opening.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action?

• Administer oxygen by face mask.

• Clear and maintain an open airway.

• Administer magnesium sulfate intravenously.

• Assess the blood pressure and fetal heart rate.

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted?

• Back pain

• Abdominal pain

• Painful vaginal bleeding

• Painless vaginal bleeding

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal?

• Light green, with no odor

• Clear and dark amber-colored

• Thick and white, with no odor

• Pale straw-colored, with flecks of vernix

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/min and regular. The client's 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?

• Contact the obstetrician.

• Continue to monitor the client.

• Report the FHR to the anesthesiologist.

• Prepare for imminent delivery of the fetus.

The nurse is developing a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply.

• Keep the room semi-dark.

• Initiate seizure precautions.

• Pad the side rails of the bed.

• Avoid environmental stimulation.

• Allow out-of-bed activity as tolerated.

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia?

• Assessing the mother's reflexes

• Taking the mother's temperature

• Taking the mother's apical pulse

• Monitoring the mother's blood pressure

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate decelerations?

• Prepare the client for a cesarean delivery.

• Monitor the fetal heart rate every 30 minutes.

• Encourage an upright or side-lying maternal position.

• Increase the rate of the oxytocin (Pitocin) infusion every 10 minutes.