Exam 15: Nursing Care During Labor and Birth

Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?

The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?

Which comfort measure should the nurse utilize in order to enable a laboring woman to relax?

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?

A laboring patient is 10 cm dilated; however, she does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)

Which patient at term should proceed to the hospital or birth center the immediately after labor begins?

The nurse is caring for a low-risk patient in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?

The pregnant patient expresses a desire to schedule birth during the baby's father's furlough from military service. The nurse explains that prior to induction of labor, it is essential to determine which clinical finding?

The nurse thoroughly dries the infant immediately after birth primarily to

The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record?

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink and the hands and feet are blue. The Apgar score for this infant is

The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places. _____ mL

Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.

A 25-year-old primigravida patient is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the patient pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely

The nurse is monitoring a patient in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)

To monitor for potential hemorrhage in the patient who has just had a cesarean birth, which action should the recovery room nurse implement?

Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and birth unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? (Select all that apply.)