Mother Baby Test 2

A client arrives at the ED in the latent phase of the first stage of labor. Which intervention should the nurse implement?

• Administer Magnesium Sulfate to speed up labor

• Provide Emotional and Physical Support

• Start the client on antibiotics to prevent infection

• Place the client into stirrups and advise her to bear down really hard until the fetus is delivered

Answer explanation

The nurse should provide emotional and physical support.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is

• 7

• 10

• 8

• 5

Answer explanation

A Bishop score less then 6 usually indicates that a cervical ripening method should be used before labor induction.

A client comes to the birthing suite and informs the nurse that "The baby is coming" and " I feel like I have to poop" It is likely the mother is in which of the following stages of labor?

• First

• Second

• Third

• Fourth

Answer explanation

When a mother states " I feel a lot of pressure" or "I want to poop" it is likely she is in the second stage of labor and the baby will be born soon.

A nurse recommends to a client in labor to try concentrating intently on a photo of ther family as a means of managing pain. The woman looks skeptical and asks "How would that stop my pain?" which explanation should the nurse give?

• It provides a mental image for your pain to be associated with in the future

• It blocks your nerve impulses from sending pain messages to the brain

• It distracts your brain from the sensations of pain

• It releases endorphins which cause you to feel euphoriac

Answer explanation

Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain.

A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?

• Heavy, irregular menses

• Oral Contraceptive use

• Recurrent Pelvic Infections

• Ovarian cysts

A client has just received combined spinal epidural. Which nursing assesment should be preformed first

• Assess vital signs

• Assess for progress in labor

• Assess deep tendon reflexes

• Asses fetal placement post epidural

Answer explanation

All answers are important but since epidurals can cause hypotension assessing vitals is priority.

The nurse is caring for a multigravida who experienced a placental abruption 4hrs ago. For which potential situation will the nurse prioritize assessment.

• Decrease in maternal blood loss

• Uterine Atony

• Hypertension

• Vaginal Prolapse

Answer explanation

A placental abruption may occur ay time before and during the labor process. After delivery, the woman who has had and abruption requires close monitoring for postpartum hemorrhage because of the risk for uterine atony.

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condtion.

• Uterine Bleeding

• Fetopelvic Disporoportion

• Low-lying placenta

• Contraction ring

Answer explanation

The woman is experience dystocia. Most likely due to hypotonic uterine dysfunction and fetopelvic disruption associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.

A primigravida client admitted with signs of labor is evaluated with External Electronic Fetal Monitoring that shows baseline FHR of 136-150 and 2 instances of FHR at 165 for 15-20 seconds. Which response should the nurse prioritize

• Immediately report to the MD that the FHR shows tachycardia

• Immediately report to the MD that the FHR shows no variability

• Before reporting to the MD Determine the short term variability

• Before reporting to the MD, determine the uterine contraction pattern

Answer explanation

The nurse needs to assess and determine if the changes are related to accelerations secondary to contraction. Asses the contraction pattern with the fetal heart rate and provide information to the MD. If the accelerations are not due to uterine contractions, Notify the MD immediately. Until then the nurse should do the assessment before reacting.

The nurse reviews a 36week gestation clients chart regarding pain management. What pain management strategies is appropriate for this client select all that apply.

• Hydrotherapy

• Sterile Water Subcutaneous injections

• Acupressure and acupuncture

• massage

Answer explanation

Hydrotherapy is not recommended for women before 37 weeks gestation. Acupuncture acupressure, sterile water sq injections and massages are all appropriate for this client.