Nokea
Before placing the fetal monitoring device on a primigravid client's fundus, the nurse performs Leopold's maneuvers. When performing the third maneuver, the nurse explains that this maneuver is done for which of the following reasons?
- A. To determine whether the fetal presenting part is engaged.
- B. To locate the fetal cephalic prominence.
- C. To distinguish between a breech and a cephalic presentation.
- D. To locate the position of the fetal arms and legs.
Correct Answer: A
Rationale: The third Leopold's maneuver assesses the presenting part's engagement in the pelvis, helping determine labor progression. Other maneuvers address cephalic prominence, presentation type, or fetal positioning.
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While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician?
- A. Red reflex in the eyes.
- B. Expiratory grunt.
- C. Respiratory rate of 45 breaths/minute.
- D. Prominent xiphoid process.
Correct Answer: B
Rationale: An expiratory grunt is a sign of respiratory distress and warrants immediate notification of the pediatrician.
While a client is being admitted to the birthing unit she states, 'My water broke last night, but my labor started two hours ago.' Which of the following is a concern? Select all that apply.
- A. Maternal lacerations.
- B. 130/80 mm Hg.
- C. Blood and mucus on perineal pad.
- D. Baseline fetal heart rate of 140 with a range between 110 and 160 with contractions.
- E. Peripad stained with green fluid.
- F. The client states, 'This baby wants out-he keeps kicking me.'
Correct Answer: E
Rationale: Prolonged rupture of membranes (>18 hours) increases infection risk, and green fluid suggests meconium, indicating potential fetal distress. Normal blood pressure, bloody show, fetal heart rate variability, and fetal movement are not immediate concerns.
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
- A. Notify the health care provider.
- B. Turn off the oxytocin (Pitocin) infusion.
- C. Turn the client to her left side.
- D. Increase the maintenance I.V. fluids.
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.
Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which of the following behaviors during this phase of labor?
- A. Excitement.
- B. Loss of control.
- C. Numbness of the legs.
- D. Feelings of relief.
Correct Answer: B
Rationale: During the transition phase (8–10 cm dilation), primigravid clients without analgesia often experience intense contractions and may feel overwhelmed, leading to a perceived loss of control. Excitement is more common in early labor, numbness of the legs is associated with epidural anesthesia, and feelings of relief typically occur after delivery.
A client who had a cesarean delivery 24 hours ago complains of pain from abdominal distention. The client has been on nothing-by-mouth status for the past 36 hours. The nurse should:
- A. Offer the client a carbonated beverage twice daily.
- B. Tell the client to use a straw when drinking fluids.
- C. Limit the client to a soft diet until more bowel sounds exist.
- D. Encourage ambulation in the hallway.
Correct Answer: D
Rationale: Ambulation promotes bowel motility, relieving abdominal distention.