NR327 Exam 2 quiz practice
questions and answers
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.
3. The cervix is completely dilated
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?
1. Administer oxygen via face mask.
2. Place the mother in a supine position.
3. Increase the rate of oxytocin intravenous infusion.
4. Document the findings and continue to monitor the fetal patterns.
1. Administer oxygen via face mask.
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The nurse is performing an assessment of a client who is scheduled
for cesarean delivery at 39 weeks of gestation. Which assessment
finding indicates the need to contact the primary health care
provider (PHCP)?
,1. Hemoglobin of 11 g/dL (110 mmol/L)
2. Fetal heart rate of 180 beats per minute
3. Maternal pulse rate of 85 beats per minute
4. White blood cell count of 12.000/mm3 (12 × 109/L)
2. Fetal heart rate of 180 beats per minute
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
3. Increased efficiency of contractions
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?
1. Variability
2. Accelerations
3. Early decelerations
4. Variable decelerations
4. Variable decelerations
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, A client in labor is transported to the delivery room and prepared
for cesarean delivery. After the client is transferred to the delivery
room table, the nurse should place the client in which position?
1. Supine position with a wedge under the right hip
2. Trendelenburg’s position with the legs in stirrups
3. Prone position with the legs separated and elevated 4. Semi-
Fowler’s position with a pillow under the knees
1. Supine position with a wedge under the right hip
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The nurse is monitoring a client in active labor and notes that the
client is having contractions every 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?
1. Notify the primary health care provider (PHCP).
2. Continue monitoring the fetal heart rate.
3. Encourage the client to continue pushing with each contraction.
4. Instruct the client’s coach to continue to encourage breathing
techniques.
1. Notify the primary health care provider (PHCP).
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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?
1. Notify the primary healthcare provider of the findings.
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