A client with a term, uncomplicated pregnancy comes into the labor-anddelivery unit in early labor saying that she thinks her water has broken. Which action by a nurse would be most appropriate?

A nurse is monitoring a client in labor and notes on the external fetal monitor that the fetal heart rate (FHR) drops with the start of each contraction. What is the priority action by the nurse?

While in the first stages of labor, a client with active genital herpes is admitted to the labor-and-delivery area. Which type of birth should the nurse anticipate for this client?

A nurse is performing Leopold’s maneuvers on a client in the early stages of labor. The nurse is most concerned when which of the following occurs?

Which position increases cardiac output and stroke volume of a client in labor?

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the most appropriate intervention by the nurse?

A client required an episiotomy for the delivery of her baby. The nurse is aware that the client may be at risk for which of the following?

A nurse has connected a laboring client to an external electronic fetal monitor. What data can the nurse expect to obtain from the monitor?

A nurse is reviewing laboratory data on a client admitted to the labor-anddelivery unit. What is the most important laboratory value for the nurse to obtain?

Which fetal position is most favorable for birth?

During the labor of a client with a breech presentation, the amniotic membranes rupture. Meconium is present in the amniotic fluid. The client asks the nurse what this means. What is the most appropriate response by the nurse?

During a vaginal examination of a client in labor, the nurse palpates the fetus’s larger, diamond-shaped fontanelle toward the anterior portion of the client’s pelvis. The nurse interprets this assessment as indicating that:

A nurse has admitted a client to the labor-and-delivery unit and is teaching her about the stages of labor. The client demonstrates an understanding of these stages when she states that birth occurs during which stage?

A client’s labor doesn’t progress. After ruling out cephalopelvic disproportion, the physician orders I.V. administration of 1,000 ml normal saline solution with oxytocin (Pitocin) 10 units to run at 2 milliunits/minute. Two milliunits/minute is equivalent to how many ml/minute?

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she’s admitted, and an electronic fetal monitor is applied. Which observation should the nurse be most concerned about?

A client in early labor is concerned about the pinkish “stretch marks” on her abdomen. Which statement by the client indicates that the nurse’s teaching has been effective?

A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and urine output of 20 ml/hour. Which action would be most appropriate?

While performing an admission nursing assessment of a client in early labor, the nurse observes a brown, raised lesion resembling a mole 2.5 in. (5 cm) below the left breast. What is the most appropriate response by the nurse?

The cervix of a 26-year-old primigravida in labor is 5 cm dilated and 75% effaced, and the fetus is at 0 station. The physician prescribes an epidural regional block. Into which position should the nurse place the client when the epidural is administered?

A client at 33 weeks’ gestation and leaking amniotic fluid is placed on an external fetal monitor. The monitor indicates uterine irritability, and contractions are occurring every 4 to 6 minutes. The physician orders terbutaline. What is the most important information for the nurse to tell the client?

A client who’s at 35 weeks’ gestation arrives at a labor-and-delivery unit leaking clear fluid from her vagina. What is the most appropriate intervention?

A client at 35 weeks’ gestation tells the nurse she’s having occasional abdominal contractions that started occurring irregularly. The contractions have remained irregular. What is the best information for the nurse to tell the client?

A client who’s at 36 weeks’ gestation comes into the labor-and-delivery unit with mild contractions. The client states that she has placenta previa. The nurse is aware that this client is at risk for which of the following?

A client at 42 weeks’ gestation is 3 cm dilated, 30% effaced, with membranes intact and the fetus at −2 (minus 2) station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes on the external fetal monitor that, for the past 10 minutes, the FHR ranged from 160 to 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which finding would indicate fetal hypoxia?

A nurse administers oxytocin (Pitocin) to a client to induce labor. The nurse determines that immediate intervention is necessary when the client presents with which finding?

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate of less than 70 beats/minute. The nurse interprets this as which of the following?

The nurse is assessing the fetal heart rate of a laboring woman who is full term. What does the nurse anticipate the fetal heart rate to be?

A client in labor has been receiving oxytocin (Pitocin) to aid her progress. The nurse caring for her notes that contractions are lasting 100 seconds. Which action should the nurse take first?

The nurse is preparing a client in labor for the administration of an epidural. What is the most important intervention by the nurse?

To detect fetal distress during labor, a nurse should be alert for which finding?