MCN INTRA

53問 • 1年前

問題一覧

Upon ultrasound, Nurse Shelby Late discovers that a pregnant patient has an anthropoid pelvis. How should the nurse explain this finding to the patient?

Transverse narrow

Nurse Shelby Late is aware that the diagonal conjugate is 12 centimeters. What is the measurement in centimeters of the obstetric conjugate?

10to10.5

Among the choices below, Nurse Shelby Late should identify the largest diameter of the fetal head to be the

verticomental

The denominator of breech presentation is the:

Sacrum

A client presents while you are covering Labor and Delivery. She is a 33-year-old G3 P2002 at term in labor with ruptured membranes. Your exam reveals 5 cm/90% effaced/0 station but you are unable to palpate fontanels or sutures. You suspect that you feel the orbital ridge in the anteroposterior diameter and the chin at 3 o'clock. If this is the case, what is the presentation?

RMT

Greta, a laboring patient and her partner have arrived at the birthing unit Which step of the admission process should be undertaken first?

Welcoming the couple

Greta presents to labor and delivery stating that her water broke 2 hours ago. Indicators of normal labor include (Select all that apply 1) FHR of 130 with average variability. 2 ) blood pressure of 130/80. 3) maternal pulse of 160. 4) protein of +1 in urine. 5) odorless, clear fluid on underwear.

1,2,&5only

The nurse is instructing Greta on tailor sitting. What is the purpose of this exercise in pregnancy?

Stretches perineal muscles

Upon examination, the nurse finds out that Greta's fetus is in an occiput posterior,position. Which intervention should the nurse use to reduce this patient's discomfort?

Massage the lower back and encourage hands and knees positioning

The nurse is preparing to assess the frequency of contractions of Greta while in labor. Which process should the nurse use to time the contractions?

The interval between the beginning of one contraction to the beginning of the next contraction

Nurse Claire Voyant admitted a laboring primigravida brought in by an anxious taxi driver. Nurse Claire Voyant calms down the similarly anxious patient by telling her that the DEFINITIVE sign that labor is about to BEGIN is

rupture of bag of water

The discomfort expected with TRUE LABOR contractions is MOST accurately described by which of the ff? Discomfort:

begins in the lower back, abdomen and then radiates over the entire abdomen

When does the membranes of a patient in labor MOST likely to rupture?

Just immediately before the labor begins.

The laboring patient has been found to be having moderately strong contractions lasting 60 seconds every 5 minutes. The fetal head is presenting at a-2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority?

Keep patient on bed rest at this time.

First stage, active phase

Visceral

Rapidly infuse 500-1,000 mL of intravenous fluids.

Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring patient in which of the following positions?

Sitting on the edge of the bed with her back slightly curved and her feet on a stool

Nurse Honey and Mahogany are assigned in a high-risk maternity ward. Here are some cases which they handled for the morning shift. Mrs. Malou Wang, 38 weeks gestation, is admitted in high-risk maternity ward. She was admitted due to labor pains with cervix of 6 cm. BP was 160/110mmHg. She is given MgSo4 per IV. How will Nurse Honey determine that the MgSo4 therapy has been effective?

Seizures are prevented.

What would Nurse Honey monitor to suspect MgSo4 toxicity on Mrs. Malou Wang?

Decreased deep tendon reflexes

If Mrs. Malou Wang begins to exhibit signs of labor after an epileptic seizure, what will Nurse Honey anticipate to occur?

Abruptio placenta.

Nurse Mahogany is assisting an obstetrician in the care of a pregnant woman in labor with herpes simplex viral infection. The nurse would anticipate which management of the condition?

Preparation for Caesarian section.

One of the patients of Nurse Mahogany has been exhibiting signs and symptoms of Rheumatic Heart Disease (RHD). These manifestation include the following, EXCEPT:

petechiae

There will be situations wherein a nurse might be needed to assist in specific therapeutic procedures assisting childbirth. Which patient requires immediate intervention by the labor and delivery nurse?

Multipara at 8 cm, systolic blood pressure has increased 35 mm Hg

The clinical nurse coordinator is meeting with a group of nursing students in post conference to teach about caring for women who undergo artificial rupture of membranes (AROM) by way of amniotomy. Which nursing student's statement indicates that the teaching has been effective?

"In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed."

The patient has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction birth. What finding is expected?

The location of the vacuum is apparent on the fetal scalp after birth.

The patient has been pushing for 2 hours and is exhausted. The fetal head is visible between contractions. The physician informs the patient that a vacuum extractor could be used to facilitate the delivery. Which statement indicates needs additional information about vacuum extraction assistance?

"I can stop pushing and just rest if the vacuum extractor is used."

A patient in labor has a spinal cord injury and is unable to effectively push with contractions. Forceps will be used. What should the nurse do to prepare the patient for this type of delivery? 1. Provide oxygen 2 L via face mask. 2. Validate that the cervix is fully dilated. 3. Determine patient's bladder is empty. 4. Begin an intravenous infusion of replacement fluid 5. Ensure patient's membranes have ruptured.

2 & 5 only

The patient's complaint is congruent with her current stage of labor.

A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions are 2 minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal pressure? When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately

continue continuous FHR monitoring.

A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions are 2 minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal pressure? Following spinal anesthesia for delivery of her baby, the woman reports an inability to void urine. As the nurse palpates the woman's bladder the woman says, "It's been 5 hours since I had my spinal and I still can't empty my bladder. Do I have nerve damage?" How should the nurse respond?

"You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you."

A pregnant patient in labor is being encouraged to push with contractions.In which position should the nurse assist to help the patient at this time?

Lying supine with legs in lithotomy stirrups

While caring for a labor patient, the nurse determines during a vaginal exam that the baby's head has internally rotated. This information is given to the family. The labor support person asks the nurse, "What other position changes will the baby undertake during labor and birth?" How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation?

Extension, restitution, external rotation, and expulsion

Which aspect of the patient's history requires notifying the physician?

Dark red vaginal bleeding

A nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care?

Defer vaginal examinations.

The pregnant patient in labor asks the nurse how soon the baby can be breastfed after delivery. What should the nurse respond to the patient?

Immediately after birth

A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make?

Prepare for an impending delivery.

The client's partner asks the nurse to explain how to know when crowning occurs. Which of the following responses should the nurse make?

"The vaginal area will bulge as the baby's head appears."

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?

Remain in a side-lying position with the head elevated.

When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?

Tachycardia.

A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the primary health care provider most likely prescribe which of the following medications?

Anticoagulants

The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which of the following client care rooms is most appropriate for this client?

A darkened private room as close to the nurses station as possible.

A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby's coming!" the client remain calm and cooperative during the imminent birth, which of the following responses by the nurse is most appropriate?

"I'll explain what's happening to guide you as we go along."

Lily, 23-year-old pregnant woman, 37th week's gestation, is admitted in the intensive care unit due to paroxysmal ventricular tachycardia. The patient is conscious: cervix is open so they decided to induce labor. When the patient was informed about induction, she asks Nurse Aurora what it is all about. Which of the following statement by the nurse is correct? Induction is a

Deliberate initiation of uterine contractions that stimulates labor

Which of the following statement is not an indication for any uterine stimulants (oxytocin)?

Preinducting cervical ripening

Oxytocin drip was started to induce labor. Which assessment findings should cause the nurse to IMMEDIATELY discontinue oxytocin infusion? [Select all that apply] 1 Fatigue and drowsiness 2 Early decelerations of the FHR 3 Uterine hyperstimulation 4 Late decelerations of the FHR

3 & 4

Simultaneous with the oxytocin drip (left arm) is the prescribed intravenous (IV) lidocaine (Xylocaine). Nurse Aurora should dilute the concentrated solution of Lidocaine (right arm) with which solution?

Normal saline 0.99 percent

Take home medications given to patient. Lily includes digitalis therapy which was given to patient since she was pregnant. Which of the following would the nurse anticipate with patient's drug therapy?

Continuation of the same dosage.

Cinderella, who is in the third trimester arrives at the hospital with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which defined complication is MOST likely causing the client's vaginal bleeding?

Premature separation of normally implanted placenta

Cinderella, who is in the third trimester arrives at the hospital with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. The abdominal pain associated with abruption placentae may be INITIALLYcaused by which of the following?

Blood in the myometrium

The bleeding following severe abruption placentae is usually caused by which of the following condition?

Hypofibrinogenemia

Abruptio placenta can cause hemorrhagic disorder which can lead to hypovolemia shock. What is the LATE sign of hypovolemic shock that the nurse should watch for?

Hypotension

The nurse should tell the client that which of the ff will occur regarding the client’s insulin needs during first trimester?

they will decrease

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS