Low risk intrapartum

The nurse is assessing the fetal station during a vaginal examination. Which of the

following structures should the nurse palpate?

1. Sacral promontory.

2. Ischial spines.

3. Cervix.

4. Symphysis pubis.

• 1. Sacral promontory

• 2- Ischial spine

• 3- Cervix

• 4- Symphysis pubis

A laboring client with an obstetrical history of G2 P1001, was admitted 1 hour ago

at 4 cm dilated and 50% effaced. She was talkative and excited at that time. During

the past 10 minutes she has become serious, closing her eyes and breathing shallowly

with each contraction. Which of the following is an accurate nursing assessment of

the situation?

• 1. The client is at risk of having a seizure.

• 2. The client is exhibiting an expected behavior for labor.

• 3. The client is becoming hypoxic and hypercapnic.

• 4. The client needs her alpha-fetoprotein levels checked.

17. The nurse enters a laboring client’s room. The client is complaining of intense back

pain with each contraction. The nurse concludes that the fetus is likely in which of

the following positions?

• 1. Mentum anterior.

• 2. Sacrum posterior.

• 3. Occiput posterior.

• 4. Scapula anterior.

18. When performing Leopold maneuvers, the nurse notes that the fetus is in the left

occiput anterior (LOA) position. Which is the best position for the nurse to place a

fetoscope to hear the fetal heart rate?

• 1. Left upper quadrant.

• 2. Right upper quadrant.

• 3. Left lower quadrant.

• 4. Right lower quadrant.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education

classes. Which of the following techniques should the nurse include in her plan

of care? Select all that apply.

1. Hypnotic suggestion.

2. Rhythmic chanting.

3. Muscle relaxation.

4. Pelvic rocking.

5. Abdominal massage.

• 1,5

• 1,2,3

• 3,4,5

• 2,5

83. A client with an obstetrical history of G2 P1001, is 5 cm dilated and 90% effaced.

She has just received an epidural. Which of the following actions is important for

the nurse to take at this time?

• 1. Assess the woman’s temperature.

• 2. Place a wedge under the woman’s side.

• 3. Place a blanket roll under the woman’s feet.

• 4. Assess the woman’s pedal pulses.

81. Which of the following actions would the nurse expect to perform before a woman

is to have regional anesthesia? Select all that apply.

1. Assess fetal heart rate.

2. Infuse 500–1,000 mL of Ringer’s lactate solution.

3. Place the woman in the Trendelenburg position.

4. Monitor blood pressure every 5 minutes for 15 minutes.

5. Have the woman empty her bladder.

• 1,2,4

• 1,2,4,5

• 1,3,5

• 2.3,5

82. Immediately following administration of epidural anesthesia, the nurse must

monitor

the mother for which of the following side effects?

• 1. Paresthesias in her feet and legs.

• 2. Drop in blood pressure.

• 3. Increase in central venous pressure.

• 4. Fetal heart rate accelerations

78. A nurse concludes that a woman is in the latent phase of labor. Which of the

following

signs/symptoms would lead a nurse to that conclusion?

• 1. The woman talks and laughs during contractions.

• 2. The woman complains about severe back labor.

• 3. The woman performs effleurage during a contraction.

• 4. The woman asks to go to the bathroom to defecate.

65. A woman is in active labor and is being monitored electronically. She has just received

fentanyl citrate 50 mcg IV for pain. Which of the following fetal heart rate

responses would the nurse expect to see on the internal monitor tracing?

• 1. Variable decelerations.

• 2. Late decelerations.

• 3. Decreased variability.

• 4. Transient accelerations