NCLEX - LABOR AND DELIVERY Day1

The nurse reviews the external fetal monitoring tracing of a client receiving an oxytocin infusion for labor augmentation. The health care provider (HCP) asks the nurse to increase the oxytocin infusion rate. Which action by the nurse is appropriate at this time?

• Ask the charge nurse to speak with the HCP.
• Increase the oxytocin infusion rate as requested by the HCP.
• Recommend to the HCP that the infusion rate be decreased at this time.
• Request that the current infusion rate be maintained due to the client's contraction pattern.
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A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate?

• Discontinue the oxytocin infusion prior to giving the medication.
• Give the medication slowly during the peak of the next contraction.
• Hold until contractions are occurring at least every 4 minutes for an hour.
• Withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication.
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A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction?

• Bishop score of 10.
• Firm and posterior cervix.
• History of precipitous labor.
• Reactive nonstress test.
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The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene?

• Documents a positive nitrazine test result when the test strip turns blue.
• Palpates the client's abdomen before applying external fetal monitors.
• Provides the client with a variety of clear liquids to drink.
• Puts on nonsterile gloves and uses soluble gel for vaginal examination.
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The nurse is reviewing fetal heart rate monitor tracings for clients who are in labor. The nurse should recognize that a client may be experiencing uterine tachysystole if contractions are

• 1-1.5 minutes apart.
• 2 minutes apart.
• 2-3 minutes apart.
• 5 minutes apart.
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The nurse is preparing to administer oxytocin to induce labor in a client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply.

• Administer oxytocin through the primary IV line.
• Assess the uterine contraction pattern.
• Initiate continuous fetal heart rate monitoring.
• Titrate oxytocin to achieve cervical dilation of 1 cm every 2 hours.
• Use an electronic infusion pump to administer IV oxytocin.

The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?

• Apply suprapubic pressure.
• Perform Leopold maneuvers.
• Perform the McRoberts maneuver.
• Assist the client to the knee-chest position.
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The nurse is performing a vaginal examination to assess cervical dilation and effacement for a client in labor. While palpating the fetal presenting part, the nurse notes a diamond-shaped structure that feels soft in the middle. Which of the following actions should the nurse take?

• Anticipate cesarean birth and prepare the client for surgery.
• Request that the health care provider verify fetal presentation.
• Document fetal presentation as cephalic in the medical record.
• Keep a gloved hand in place to elevate the fetal presenting part.
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The nurse is caring for a client at 39 weeks gestation who is receiving an IV oxytocin infusion for induction of labor. The nurse notes recurrent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply.

• Administer an IV fluid bolus.
• Reposition the client laterally.
• Discontinue the IV oxytocin infusion.
• Prepare the client for an amnioinfusion.
• Apply abdominal vibroacoustic stimulation.

The nurse is caring for a client in active labor who is 8 cm dilated, trembling, and reporting the urge to push. Which of the following actions should the nurse take?

• Administer IV meperidine.
• Place the client in the supine position.
• Instruct the client to bear down and push.
• Provide coaching for breathing techniques.
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