1.  The nurse is calculating the pregnant client’s obstetrical history. The client reports having one miscarriage at 10 weeks and one child born at 39 weeks. What number should the nurse document on the client’s medical record for gravida?

            a. 2

            b. 3

            c. 1

            d. 4

. B. 3

            G refers to the number of pregnancies not births or fetuses thus the pregnant mother has been pregnancy twice before and is currently pregnant totaling three.

2. The delivery nurse is reporting to the postpartum nurse about the client who just delivered her first baby, a term newborn. Which number should the delivery nurse report for the client’s parity?

            a. 2

            b. 3

            c. 1

            d. 4

c.

The client has given birth to her first child; her parity is 1.

3. Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?

a. Immediately begin to massage the uterus

b. Document the findings of the fundus

c. Assess the client for bladder distention

d. Monitor for increased vaginal bleeding

Answer b:

            b. Immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding.

a. Uterine massage is indicated only if the uterus does not feel firm and contracted.

c. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen.

d. The uterus is firm; there is no reason to infer that increased vaginal bleeding would occur.

4. The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.

1. Place the side of one hand just above the client’s symphysis pubis.

2. Press deeply into the abdomen.

3. Place the other hand at the level of the umbilicus.

4. Massage the abdomen in a circular motion.

5. Position the client in the supine position.

6. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage.

a. 5, 1, 4, 3, 6, 2

b. 5, 4, 1, 3, 2, 6

c. 5, 1, 3, 2, 4, 6

d. 5, 3 ,1, 2, 4, 6

. Answer C:

            ANSWER: 5, 1, 3, 2, 4, 6

5. Position the client in supine so the height of the uterus is not influenced by an elevated position.

1. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation.

3. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery.

2. Press deeply into the abdomen to allow the massage to reach the fundus.

4. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined.

6. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.

5. The nurse is caring for the 30-weeks-pregnant client who is having contractions every 11 /2 to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. The nurse determines that delivery is imminent. What intervention is the most important at this time?

a. Administering a tocolytic agent

b. Providing teaching information on premature infant care

c. Notifying neonatology of the impending birth

d. Preparing for a cesarean section birth

Answer C:

            c. The most important intervention is to notify the neonatal team of the delivery because the team members will be needed for respiratory support and possible resuscitation.

a.  Tocolytic agents, such as nifedipine (Procardia), can be used for short-term intervention to slow down contractions and delay birth, but it is too late to administer a tocolytic agent.

b. Teaching is important but is not appropriate at this time.

c. A cesarean birth is indicated if there are other obstetrical needs.

6. The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately?

a. Turn the client onto her left side.

b. Turn the client onto her right side.

c. Notify the attending obstetrician

d. Apply oxygen by nasal cannula.

a.

When the laboring client lies flat on her back, the gravid uterus completely occludes the inferior vena cava and laterally displaces the subrenal aorta. This aortocaval compression reduces maternal cardiac output, producing dyspnea, diaphoresis, tachycardia, and hypotension. Other symptoms include air hunger, nausea, and weakness. A left side-lying position decreases aortocaval compression. b.  Lying on the right side increases aortocaval compression. c. Notifying the obstetrician is not the first intervention. The obstetrician would be notified if symptoms are not relieved by a left side-lying position. d. Applying oxygen may be needed, but first the client should be placed left side-lying.

7. The nurse discovers that an African couple from Kenya has not named their 48-hour-old, full-term newborn, and the infant and mother are being discharged to home. Which action should the nurse take in response to this information?

a. Ask the parents to choose a name before discharge.

b. Encourage other appropriate attachment behaviors.

c. Document the discharge and that the baby is unnamed.

d. Delay discharge until parental attachment is addressed.

In Kenya, the naming of a child is an important event. In some areas, the name is given on the third day after birth and is marked by a celebration. Therefore, the only intervention needed is to document this information.

a. It would be culturally inappropriate to ask the parents to choose a name before discharge.

b. It is always appropriate for the nurse to observe for and encourage attachment behaviors; however, in this situation, not naming the infant is not a sign of inappropriate attachment.

d. There is no need to delay discharge; not naming the infant is not a sign of inappropriate attachment.

8. What are the five factors or “P’s” affecting the process of labor and birth.

            a. Passenger, passageway, powers, position, psychologic responses

            b. Person, placenta, passenger, powers, position

            c. Passenger, placenta, powers, position, psychologic responses

            d. Position, pattern, powers, passenger, psychologic responses

a.

Passenger, passageway, powers, position, psychologic responses

9. The laboring client is at 5/100/0, ROA, and having difficulty coping with her contractions. She does not want an epidural analgesia or medications. How can the nurse best assist the client and her partner at this time?

a. Apply counterpressure to sacral area with a firm object.

b. Implement effleurage (light massage) of the abdomen.

c. Provide a quiet, calm, and relaxed labor environment.

d. Re-emphasize modified-paced breathing techniques.

d.

Breathing techniques provide distraction, reduce pain perception, and help the client maintain control during labor. The modified-paced breathing technique is usually more effective during active labor (4–7 cm). The client is at 5 cm. The modified-paced technique is performed at about twice the normal breathing rate and requires that the client remain alert

a. Counterpressure can be helpful to cope with internal pressure sensations and pain in the lower back when the fetus is in posterior position. The fetus is ROA or right occiput anterior position. b. Effleurage can distract from contraction pain during the latent phase of the first stage of labor. This client is in active labor, and as labor progresses, hyperesthesia occurs, increasing the likelihood that effleurage will be uncomfortable and less effective. 

c. Providing a quiet, calm, and relaxed labor environment should be part of the nursing responsibilities to help the client cope with contractions, but this is not the best option. 

10. The nurse explained the process of cervical effacement to the client in early labor. Which statement by the client indicates that she understands the information?

a. “The cervix will widen from less than 1 cm to about 10 cm.”

b. “The cervix will pull or draw up and become paper-thin.”

c. “The cervical changes will cause my membranes to rupture.”

d. “The cervical changes will help my baby to change position.”

b.

In cervical effacement, the cervix progressively changes from a thick and long structure, to paper thin. This statement indicates that the client understands the information.

a. Widening of the cervix describes cervical dilation, not effacement. 

c. Cervical changes will not cause membranes to rupture. The power of contractions causes cervical changes (effacement and dilation) and, possibly, membrane rupture.  d. Cervical changes will not help the fetus to change position. Fetal descent is thought to occur from the pressure of contractions, especially from the fundus, and from the pressure of the amniotic fluid. Fetal position changes also occur from the fetal head and body adjusting to the maternal pelvis as they descend.

11. The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor?

a. Lengthening of fetal cord

b. Increased bloody show

c. A strong urge to push

d. More frequent contractions

a.  

The third stage of labor lasts from the birth of the baby until the placenta is expelled. Lengthening of the fetal cord is one of several signs indicating placental separation.

b. Bloody show is pink and mucoid in nature and occurs during the first and second stages of labor. During the third stage, there may be increased vaginal bleeding that is bright or dark red. c. A strong urge to push may occur during the first and second stages of labor.

d. More frequent contractions occur during the first and second stages of labor.

12. The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?

a. Cloudy in color

b. Has a strong odor

c. Meconium stained

d. Has a pH of 7.1

d.

4. The pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material.

 a. Normal amniotic fluid should be clear. Cloudiness could indicate the presence of meconium or an intrauterine infection.

b. Amniotic fluid should have no odor. Any odor may indicate the presence of infection.

c. Amniotic fluid should be clear. Meconium stained could indicate fetal distress. 

13. The laboring multigravida client’s last vaginal examination was 8/90/+1 (8 cm, 90 Effaced, station +1). The client now states feeling rectal pressure. Which action should the nurse perform first?

a. Encourage the client to push.

b. Notify the obstetrician or midwife.

c. Help the client to the bathroom.

d. Complete another vaginal exam.

d.

The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part

a. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process.

b. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife.. 

14. The client admitted in preterm labor is told that an amniocentesis needs to be performed. The client asks the nurse why this is necessary when the HCP has been performing ultrasounds throughout the pregnancy. Which is an appropriate response by the nurse?

a. “Your baby is older now, and an amniocentesis provides us with more information on how your baby is doing.”

b. “An amniocentesis could not be performed before 32 weeks, so you will be having this test from now until delivery.”

c. “Your doctor wants to make sure that there are no problems with the baby that an ultrasound might not be able to identify.”

d. “With your preterm labor your doctor needs to know your baby’s lung maturity; this is best identified by amniocentesis.”

d.

The amniocentesis is being performed to determine fetal lung maturity. Once fetal lung maturity is determined, appropriate care can be planned, including administration of betamethasone, administration of tocolytics, or delivery of the baby.

a. While an amniocentesis can provide fetal information that an ultrasound cannot, the rationale for the amniocentesis is to determine lung maturity. Stating additional information is too broad.

b. An amniocentesis can be performed as early as 12 weeks’ gestation, not after 32 weeks.

c. The amniocentesis is not being performed to identify fetal anomalies.

15. A 25-year-old primiparous client arrives for her first prenatal visit at 10 weeks’ gestation. She seems nervous and has many questions. What is the most important intervention by the nurse?

a. Address the client’s concerns while taking a comprehensive history

b. Ask the client to undress to prepare for the physical examination

c. Reassure the client that all her questions will be answered during the visit.

d. Tell the client there’s nothing to worry about. The health care provider will take good care of her.

16. One parent is present with the 14-year-old client who is to have an emergency appendectomy. The nurse has been asked to have the informed consent form signed. Which statement reflects the nurse’s best thinking about informed consent?

a. A signed informed consent form ensures client knowledge of the risk and benefits of the procedure.

b. Adolescents have the ability to make decisions for themselves and may sign the informed consent form.

c. Both parents have legal rights regarding medical treatment. Without both parents present, the informed consent form may not be signed.

d. The surgeon is responsible for obtaining informed consent and for explaining the surgical procedure, benefits, and potential risks.

22. The nurse is assessing the appropriateness of a self-help group for the 20-year-old client

a. recently diagnosed with an eating disorder. The nurse should initially obtain which information? The average age of the self-help group’s membership

b. The ratio of clients to involved health care professionals

c. How compatible the group’s meeting schedule is with the client’s expectations

d.  The composition of the self-help group’s membership and similarity with the client

23. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?

a. The membranes must rupture

b. The fetus must be at 0 station

c. The cervix must be dilated fully

d. The patient must receive anesthesia

24.  Ultrasound on the fetus of the 40 week primigravida in the cephalic vertex presentation at Station +1 with 100 effaced and 10 cm dilation.  What should the nurse do first?

            a. Contact the physician or midwife for delivery

            b. Prepare the mother for a cesarean section due the fetus presentation

            c. Do a vaginal examination

            d. contact the physician to perform the Leopold's Maneuver 

25. What are the seven cardinal movements of the mechanism of labor?

            a. axis position, descent, flexion, internal rotation, extension, external rotation, delivery

            b. engagement, descent, flexion, internal rotation, extension, external rotation, expulsion

c. engagement, descent, internal rotation, external rotation, positioning, extension, expulsion

            d. axis position, descent, station, internal rotation, extension, external rotation, expulsion.

b.

The seven cardinal movements include:

a.       Engagement: the biparietal diameter of the head passes the pelvic inlet, the head is said to be engaged in the pelvic inlet

b.      Descent: the progress of the presenting part through the pelvis. (Page 352)

c.       Flexion: Flexion permits the smaller suboccipitobregmatic diameter (9.5 cm) rather than the larger diameters to present to the outlet. They normally flexes so the chin is brought into closer contact with the fetal chest.  (Page 353)

d.      internal rotation: The pelvic inlet is widest in the transverse diameter; therefore the fetal head passes the inlet into the true pelvis in the occipitotransverse position. The outlet is widest in the anteroposterior diameter; for the fetus to exit the head must rotate.  Rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. (Page 353)

e.       extension: The stretching out process after the head reaches the perineum and extends under the lower border of the symphysis pubis.  (Page 353)

f.       external rotation (restitution): The 45-degree turn realigns the infant’s head with her or his back and shoulders for the final rotation as the anterior shoulder emerges after the head. (Page 353)

g.   expulsion   the trunk of the baby is born by flexing it laterally in the direction of the symphysis pubis. (Page 353)

26. The primigravida client in the active stage of labor with her first pregnancy states, “I just sneezed and think I urinated all over myself; I feel wet.” Which action is the nurse’s priority?    a. Offer the client the bedpan.

b. Inspect the client’s perineal area.

c. Change the client’s gown and bed linens.

d. Tell the client to begin using her breathing techniques

b.

The nurse’s priority should be to assess the perineum to determine if rupture of the membranes has occurred. A nitrazine strip test can be done to check fluid leaking from the vaginal introitus, but contamination of the strip with urine could result in false-positive test results.

a. Placing the client on the bedpan is not a priority; membrane rupture should first be determined.

c. Changing the gown and linens should be done after ruling out ruptured membranes.

d.  Although breathing may be helpful during contractions, the woman is already in the active phase of labor, and typically breathing techniques are addressed in the latent phase.

27. The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?

a. Transition

b. Active

c. Active pushing

d. Latent

d.

During the latent phase (1–3 cm), the client is usually happy and talkative.

a. During the transition phase (8–10 cm), the client is usually more restless, irritable, and more likely to lose control.

b. During the active phase (4–7 cm), the client may become more anxious and fatigued and needs to concentrate on breathing techniques to cope with the increasingly stronger contractions.

c. The client who is actively pushing is focusing on how effective she is in the descent of the fetus and concentrating on how she is coping with contractions. She is usually not expressing happiness or laughter, and is not talkative. 

28. The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?

a. Conclude that there is a problem with the baby and call for help.

b. Check that there is adequate gel under the transducer and reposition.

c. Give the client oxygen via facemask at 8 to 10 liters per minute.

d. Auscultate fetal heart rate by fetoscope and assess maternal vital signs.

b.

When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem.

a. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR..

c. There is no indication to give oxygen to the client.

d. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.

29. The pregnant client presents with regular contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?

a. The client is experiencing early labor.

b. The client is experiencing false labor.

c. The client has experienced cervical ripening.

d. The client has experienced lightening.

a.

Early labor is a pattern of labor that occurs when contractions become regular and the cervix dilates to 3 cm.

b. False labor occurs when Braxton-Hicks contractions are strong enough for the client to believe she is in actual labor. The contractions are infrequent or do not have a definite pattern. The lack of cervical change is also consistent with false labor. The latent phase is characterized by regular contractions, although fetal descent may not occur.

c. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. There is no information in the stem about cervical ripening.

d.  Lightening is settling or lowering of the fetus into the pelvis. Lightening can occur a few weeks or a few hours before labor. There is no information in the stem about lightening.

30. The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions?

a.  “I should wear panty hose.”

b. “I should wear support hose.”

c.“I should wear flat nonslip shoes that have good support.”

d.  “I should wear knee-high hose, but I should not leave them on longer than 8 hours.”

d.

31. An active 19-year-old primigravida attends the prenatal clinic for the first time. She asks the nurse if she can continue playing tennis and go horseback riding while she is pregnant. How should the nurse reply?

a. "Continue your usual activities as long as you are comfortable."

b. "Horseback riding is acceptable, but only up to the last trimester"

c.  "Tennis is good exercise for you, but horseback riding is too strenuous."

d.  "Both of these sports have been found to be too strenuous for a pregnant woman."

a.

32. What does the bearing-down effort have on the fetus?

            a. minimal because it is part of the normal process.

            b. results in an increase in heart rate due to the pressure

            c. decreases fetal oxygenation and heart rate

            d. cardiac pause which resumes after the contraction

c.

33. When the nurse is completing the history of the 16-year-old client at a clinic, the client says, “I think that I might be pregnant.” What is the nurse’s best response?

a. “How long have you been sexually active?”

b. “Why do you think you are pregnant?”

c. “Who have you spoken to about this?”

d. “When was your last menstrual cycle?”

d.

A direct question related to the client’s menstrual cycle is best and is necessary prior to obtaining other information

a. Although determining sexual activity of a teenager is important for client teaching, the nurse’s best response should be obtaining information pertaining to the pregnancy.

b. Asking a “why” question may make the client defensive.

c. This is an acceptable question, but the nurse needs to begin with the facts. 

34. While assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client’s breasts are hard and painful. Which interventions should not be implemented by the nurse? Select all that apply.

a. Tell her to feed a small amount from both breasts at each feeding.

b. Apply ice packs to the breasts at intervals between feedings.

c.  Administer an anti-inflammatory medication prescribed prn.

d. Apply warm, moist packs to the breasts between feedings. 

a.

Moving the baby from the initial breast to the second breast during the feeding, before the initial breast is completely emptied, may result in neither breast being totally emptied and thus promote continued engorgement.

b. Because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. 

c.  Administering anti-inflammatory medication will decrease breast pain and inflammation.

d. Because heat application increases blood flow, moist heat packs would exacerbate the engorgement.

35. The pregnant client asks the nurse, who is teaching a prepared childbirth class, when she should expect to feel fetal movement. The nurse responds that fetal movement usually can first be felt during which time frame?

a. 8 to 12 weeks of pregnancy

b. 12 to 16 weeks of pregnancy

c. 18 to 20 weeks of pregnancy

d. 22 to 26 weeks of pregnancy

c.

Subtle fetal movement (quickening) can be felt as early as 18 to 20 weeks of gestation, and it gradually increases in intensity.

a. Eight to 12 weeks of pregnancy is too early to expect the first fetal movement to be felt.     b. Twelve to 16 weeks of pregnancy is too early to expect the first fetal movement to be felt. c.  Twenty-two to 26 weeks of pregnancy is later than expected to feel the first fetal movement.

36.  Which month are the fetus’ neuro pathways responding to stimulation?

            a. Month 2

            b. Month 4

            c. Month 9

            d. Month 7

d. The seventh month is when the neuro pathways are responding to stimuli.

      a. The second month is when an ultra sound can Doppler a fetal heart sound.

      b. The fourth month is when the fetus shows up on x-rays due to the formation of bones.

       c. The ninth month should be when the fetus is in the birth canal with their head first facing   towards the mother’s spinal cord.

37. One measure’s the fundus height from what two points?

            a. between the umbilicus and the pelvic bone

            b. between the iliac crest and the diaphragm

            c. between the pubic bone to the top of the uterus

            d. between the pubic bone to the pelvic bone

38. A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes the woman’s perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time?

a. Request a prescription to administer oxytocin.

b. Perform an in-and-out catheter immediately.

c. Measure blood loss by measuring perineal pad.

d. Check fundus for position and consistency.

d.

While the greatest risk of postpartum hemorrhage is within the first hour following birth, a woman can develop an early postpartum hemorrhage anytime within the first 24 hours postbirth. As soon as the nurse notices an increased amount of lochia and clots, the fundus must be assessed for firmness and position. Normally, it should be firm, midline, and either just above or below the umbilicus. Massaging the fundus if it is not firm will assist with a uterine contraction to help decrease blood loss postpartum.

a. Administering oxytocin would not be the first action for the nurse to take.

b. Performing an in-and-out catheterization at this time is not appropriate. The nurse should assist the woman to the washroom to void on her own first.

c. The nurse can measure the blood loss by measuring the perineal pad; however, this would be done after the nurse has first assessed the fundus.

39. The nurse is discussing dietary concerns with pregnant teens. Which of the following choices is convenient for teens but not nutritious for both the mother and fetus?

a. milkshake or yogurt with fresh fruit or granola bar

b. chicken nuggets with tater tots

c. cheese pizza with spinach and mushroom topping

d. peanut butter with crackers and a juice drink

b.

Fried foods, such as chicken nuggets and tater tots, and foods such as cheeseburgers and buttered popcorn are high in fat; carbonated drinks such as diet colas, and foods such as pickles and ketchup contain large amounts of sodium. These foods can lead to an increase in ankle edema and promote weight gain from empty calories.  Dairy products, fresh fruit, vegetables, and foods high in protein (like cheese and peanut butter) are excellent choices. 

41. Which lie of the fetus requires a cesarean section?

            a. longitudinal

            b. transverse

            c. oblique

            d. breech

42. Where is the external fetal monitor leads placed?

            a. above the pubic bone

            b. anterior lateral to the iliac crest

            c. 2 cm to the left of umbilicus

            d. placed over the fundus where the loudest heart tones are heard.

d.

External fetal monitoring leads are placed over the fundus where the loudest heart tones are heard.

43. What needs to have occurred before applying internal fetal monitoring leads?

            a. mother needs to have moved from latent to active phase

            b. the contractions need to be regular

            c. the fetus must be in distress before monitoring interially.

            d. the membranes ruptured and cervix dilated

 44. What is not a sign of prelabor?

            a. mucous plug

            b. cervix ripening

            c. begins dilating

            d. Ferguson reflex

45. What occurs during the third stage of labor?

            a. fetus is delivered

            b. homeostasis reestablished

            c. placenta delivered

            d. the descent phase

 46. Prolactin is used to:

            a. to improve abnormal FHR patterns

            b. to relax the uterus

            c. augment existing contractions

            d. minimize soft-tissue damage

47. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by:

a. Noting if the heart rate is greater than 140 BPM

b. Placing the diaphragm of the Doppler on the mother’s abdomen

c. Performing Leopold’s maneuvers first to determine the location of the fetal heart

d. Palpating the maternal radial pulse while listening to the fetal heart rate

48. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

a. Three contractions occurring within a 10-minute period

b. A fetal heart rate of 90 beats per minute

c. Adequate resting tone of the uterus palpated between contractions

d. Increased urinary output

49. A client is experiencing pain during the first stage of labor. What should the nurse instruct the client not to do to manage her pain?

a. Walk in the hospital room.

b. Use slow chest breathing.

c. Request pain medication on a regular basis.

d. Lightly massage the abdomen.

c.

Pain medication is not used during the first stage of labor because most medications will slow labor; anesthesia may be considered during the second stage of labor.Pain during the first stage of labor is primarily caused by hypoxia of the uterine and cervical muscle cells during contraction, stretching of the lower uterine segment, dilatation of the cervix and perineum, and pressure on adjacent structures.

a. Ambulating will assist in increasing circulation of blood to the area and relaxing the muscles. b. Slow chest breathing is appropriate during the first stage of labor to promote increased oxygenation as well as relaxation.

d. The woman or her coach can lightly massage the abdomen (effleurage) while using slow chest breathing. Chest breathing and massaging increase oxygenation and relaxation of uterine muscles. Sipping ice water, while helpful for maintaining hydration, will not be useful as a pain management strategy.