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The nurse is monitoring a client receiving oxytocin for labor induction. What finding requires the nurse to take immediate action?
- A. Contractions lasting 90 seconds.
- B. Contractions every 2–3 minutes.
- C. Fetal heart rate of 180 beats/minute.
- D. Client reports mild nausea.
Correct Answer: C
Rationale: A fetal heart rate of 180 bpm indicates tachycardia, which may suggest fetal distress requiring immediate intervention.
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A client in labor is receiving epidural anesthesia. What is the priority nursing intervention?
- A. Monitor maternal heart rate.
- B. Assess for bladder distention.
- C. Check maternal blood pressure frequently.
- D. Encourage frequent position changes.
Correct Answer: C
Rationale: Frequent monitoring of maternal blood pressure is essential to detect and manage hypotension caused by epidural anesthesia.
A laboring patient's obstetrician suggested an amniotomy as a method for inducing the labor. Which assessment must be made before the amniotomy is performed?
- A. Fetal presentation, position, and station
- B. Estimate fetal birth weight
- C. Maternal temperature, BP, pulse
- D. Biparietal diameter
Correct Answer: A
Rationale: Before performing an amniotomy (artificial rupture of membranes), it is essential to assess the fetal presentation, position, and station. This assessment helps ensure that the procedure is performed safely without causing harm to the baby. Knowing the fetal presentation (such as breech, transverse, or vertex), position (occiput anterior, occiput posterior, etc.), and station (how far down the baby's head is in the pelvis) allows the obstetrician to determine the best approach and technique for the amniotomy. It also helps in reducing the risk of complications during labor induction and delivery. Therefore, this assessment is crucial in ensuring the well-being of both the mother and the baby during the labor process.
Which assessment finding indicates uterine rupture?
- A. Ctx abruptly stop during labor
- B. Fetal tachycardia occurs
- C. Client becomes dyspneic
- D. Labor progressing unusually quickly
Correct Answer: A
Rationale: Uterine rupture is a rare but serious obstetric emergency that can occur during labor and delivery. One of the key assessment findings indicating uterine rupture is when contractions (ctx) abruptly stop during labor. This abrupt cessation of contractions can be a sign that the uterine muscle has torn due to excessive pressure or force, leading to a disruption in the normal progress of labor. Other signs and symptoms of uterine rupture may include severe abdominal pain, abnormal fetal heart rate patterns, loss of fetal station, and signs of hypovolemic shock in the mother. Immediate intervention and surgical management are required in cases of uterine rupture to ensure the safety of both the mother and the baby.
A patient who was diagnosed prenatally as having epidural for pain management. What should the greater than 2,000 mL of amniotic fluid just deliv- nurse be prepared to do? Select all that apply. ered a 9 lb (4,082 g) baby girl. Her nurse is aware
- A. Assess maternal vital signs that she is now at risk for which condition?
- B. Assess FHR
- C. Infection
- D. Assist patient to the bathroom to void
Correct Answer: A
Rationale: A. Assess maternal vital signs: With the delivery of a baby with macrosomia (greater than 4,000 g), the mother is at risk for postpartum hemorrhage due to uterine atony, retained placental fragments, or lacerations. Therefore, assessing maternal vital signs is crucial in detecting any signs of hemorrhage promptly.
The nurse is educating a client about Rh incompatibility. What statement indicates understanding?
- A. Rh incompatibility only occurs in first pregnancies.
- B. I will need Rho(D) immune globulin if my baby is Rh positive.
- C. Rh incompatibility is treated with antibiotics.
- D. Rh incompatibility does not affect the baby.
Correct Answer: B
Rationale: Rho(D) immune globulin prevents the mother's immune system from attacking Rh-positive fetal red blood cells.