Labor and Birth

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is dilated completely.
4. The client begins to expel clear vaginal fluid.
5. The Ferguson reflex is initiated from perineal pressure.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)?

The nurse is reviewing the record of a client in the labor room and notes that the primary health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? Refer to figure.

A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

1. Less pressure on her cervix
2. Decreased number of contractions
3. Increased efficiency of contractions
4. The need for increased maternal blood pressure monitoring
5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

The nurse is monitoring a client in active labor and notes that the client is having contractions ever 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate?

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client’s abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

Which assessment finding after an amniotomy should be conducted first?

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client’s primary physiological need at this time?

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client’s contractions are moderate and occurring every 2 to 3minutes,with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action?