The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately?

The nurse is assessing the Hispanic client who is in the active stage of labor. Which is the most crucial information that the nurse should assess related to the client’s ethnicity and stage of labor?

The nurse is about to auscultate an F HR on the client in triage. What information should the nurse determine first in order to find the correct placement for auscultation?

The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?

The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of detemiining fetal position in this client?

The laboring client’s amniotic membranes have just ruptured. Which nursing action should be priority?

The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor?

The labor nurse observes a sinusoidal FHR pattern on the monitor tracing. How should the nurse interpret this pattern?

The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?

The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?

The nurse is caring for the Muslim client in labor. What should the nurse be most aware of as a possible belief of the client?

The nurse explained the process of cervical effacement to the client in early labor. Which statement by the client indicates that she understands the information?

The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document?

The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/—2. How should the nurse respond to the client’s request?

The primigravida client has been pushing for 2 hours when the infant’s head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse’s interpretation of this information?

The pregnant client presents with regular contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?

The nurse assesses the pregnant client who comes to the triage unit and determines that she is at 4/50/—l and that the fetal HR is 148. What priority information should the nurse collect before proceeding?

The laboring client is at 5/100/0, RCA, and having difficulty coping with her contractions. She does not want an epidural analgesia or medications. How can the nurse best assist the client and her partner at this time?

The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?

The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?

The laboring multigravida client’s last vaginal examination was 8/90/+1. The client new states feeling rectal pressure. Which action should the nurse perform first?

The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?

The nurse is caring for the client in pretemi labor who has gestational diabetes. The nurse determines that the client has a reactive NST when which findings are noted?

The client in labor received an epidural anesthesia 20 minutes ago. The nurse assesses that the client’s BP is 98/62 mm Hg and that the client is lying supine. What should the nurse do next?

The client has been in labor for 21 hours. Induction was started 16 hours ago, and she is now dilated 5 cm. She has made little progress, and there has been no fetal descent. The I-ICP identifies cephalopelvic disproportion (CPD). The nurse should prepare the client for which mode of delivery?

The nurse is reviewing laboratory results of the client in labor prior to her receiving epidural anesthesia. Which result is most important to report to the HCP prior to the initiation of the epidural?

The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?

The 39-year-old client with type 1 DM presents at 36 weeks’ gestation with regular contractions. An HCP decides to do an amniocentesis. Which statement best supports why the nurse and NA should prepare the client for an amniocentesis now?

The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/lOO/—2, RSP. How should the oncoming shift nurse interpret this documentation?

The nurse is caring for multiple clients. The nurse determines that which client would be a candidate for intermittent fetal monitoring during labor?

The nurse practitioner informs the new nurse that the laboring client’s monitor is showing prolonged decelerations. Which interpretation by the new nurse is correct?

The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?

At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next?

The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?

The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 1005- How should the nurse document this FHR?

The full-term pregnant client presents with bright red vaginal bleeding and intense abdominal pain. Her BP is 150/96 mm Hg, and her pulse is 109 bpm. The nurse should immediately implement interventions for which possible complication?

The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?

The laboring client suddenly experiences a dramatic drop in the FHR from the 1505 to the 1105. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?