Exam 13: Nursing Care During Labor and Birth

At 5 minutes after birth, the nurse assesses that the neonate's heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign?

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

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, but the hands and feet are blue. The Apgar score for this infant is:

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

The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head?

The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter?

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

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

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

Which should the nurse recognize as being associated with fetal compromise?

The nurse examines a primipara's cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse's priority action?

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

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

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

When using the second Leopold's maneuver in fetal assessment, the nurse would palpate (the):

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

Which interventions are required following an amniotomy procedure? (Select all that apply.)

Which is an essential part of nursing care for a laboring client?

The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time?