Exam 15: Nursing Care During Labor and Birth

The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). What is the priority nursing action for this patient?

The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?

Which breech presentation should the nurse recognize as being favorable for an external cephalic version?

On vaginal exam, the patient's cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishop's score for this patient is

Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth?

A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences

After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?

While assisting with a vacuum extraction birth, which alteration should the nurse immediately report to the obstetric provider?

Which of the following behaviors would be applicable to a nursing diagnosis of "risk for injury" in a patient who is in labor?

Which clinical finding would be an indication to the nurse that the fetus may be compromised?