A nurse is caring for a client who is in the first stage of labor with report of ruptured membranes prior to admission to the labor unit. The nurse observes the fetal heart rate changes baseline from 150/min to 110/min. during a vaginal exam. The nurse notes a pulsation at the cervix. Which of the following actions should the nurse perform first? Push the cord back into the cervical os Prepare the woman for immediate vaginal birth Place the client in the supine position Insert a gloved hand into the vagina to lift the presenting part off of the cord.
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.A nurse is caring for a client who is in the first stage of labor with report of ruptured membranes prior to admission to the labor unit. The nurse observes the fetal heart rate changes baseline from 150/min to 110/min. during a vaginal exam. The nurse notes a pulsation at the cervix. Which of the following actions should the nurse perform first?
Push the cord back into the cervical os
Prepare the woman for immediate vaginal birth
Place the client in the supine position
Insert a gloved hand into the vagina to lift the presenting part off of the cord.
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- A nurse is preparing to care for a client in labor. The physician has prescribed an intravenous infusion of oxytocin (Pitocin). The nurse ensures that continuous fetal monitoring was implemented before initiating the infusion. The nurse is caring for patients on induction of labor. Which of the following patients would the nurse consider a priority to have successful induction of labor? Multiparous; cervix 1 cm dilated/20% effaced/station 0 primiparous ; cervix 2 cm dilated/20% effaced/station -1 primiparous ; cervix 2 cm dilated/20% effaced/station 0 multiparous ; cervix 2 cm dilated/80% effaced/station -1A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate to heavy, bright red, and is tricking from the vagina. The nurse located the fundus at the umbilicus: it is firm and midline, with no palpable bladder. The client’s vital signs remain at their baseline. Based on the information, the nurse would implement which of the following actions? Document the findings as normal Increase IV rate Recheck the admission hematocrit and hemoglobin levels Report the findings to the healthcare providerYou are working as a Labor and Delivery Nurse at a local hospital. Patient A.M., a 26 year old G3 P2 (2002) at 41 weeks of gestation came in having contractions and feeling uncomfortable. Upon internal examination, the cervix was found to be 3 cm dilated. Fundic height was noted to be 40 cm. She was then admitted for monitoring of labor and delivery. She was initially advised to continue mobilizing. Obstetrical history was taken and documented. Her first baby was delivered 4 years ago via normal spontaneous delivery with birthweight of 3,700 grams. The second baby was delivered 2 years ago via forceps delivery with birthweight of 3,900 grams. In this pregnancy, she was diagnosed to have gestational diabetes mellitus at 28 weeks age of gestation. Pelvic ultrasounds were normal and antennal care was unremarkable. The baby was moving actively normal prior to labor. Four hours later, spontaneous rupture of membranes occurred. She was examined again and the cervix…
- You are working as a Labor and Delivery Nurse at a local hospital. Patient A.M., a 26 year old G3 P2 (2002) at 41 weeks of gestation came in having contractions and feeling uncomfortable. Upon internal examination, the cervix was found to be 3 cm dilated. Fundic height was noted to be 40 cm. She was then admitted for monitoring of labor and delivery. She was initially advised to continue mobilizing. Obstetrical history was taken and documented. Her first baby was delivered 4 years ago via normal spontaneous delivery with birthweight of 3,700 grams. The second baby was delivered 2 years ago via forceps delivery with birthweight of 3,900 grams. In this pregnancy, she was diagnosed to have gestational diabetes mellitus at 28 weeks age of gestation. Pelvic ultrasounds were normal and antennal care was unremarkable. The baby was moving actively normal prior to labor. Four hours later, spontaneous rupture of membranes occurred. She was examined again and the cervix was still at 3 cm. An…A group of student-nurses are about to conduct a community diagnosis. Which of the following activity is necessary during the first stage? Refer Julia immediately to an OBGyn doctor and have her checked in a hospital since she has high risk pregnancy Assist the family in providing adequate care to Julia by doing a daily home visit and Leopold’s Maneuver Discuss to Julia’s family the importance of regular prenatal check-ups Emphasize to Julia that health center services are freeA client in the early stages of labour who was admitted to the labour unit with reports of ruptured membranes is being attended to by a nurse. During a vaginal check, the nurse notices that the foetal heart rate drops from 150 beats per minute to 110 beats per minute. A pulse near the cervix is noted by the nurse. Which of these tasks should the nurse carry out first? A. Push the cord back into the cervical os B. Prepare the woman for immediate vaginal birth C. Place the client in the supine position D. Insert a gloved hand into the vagina to lift the presenting part off of the cord.?
- Uncomplicated labor with vaginal delivery at 38 weeks gestation. Liveborn single infant weighing 7 pounds, 8 ounces at birth. The delivering obstetrician has followed the patient throughout her pregnancy and will also be providing the post partum care for this patient. CPT Code(s): ICD-10-CM Code(s): ( there are 3 ICD codes)A client with an internal fetal monitor catheter in place has just received IV butorphanol (Stadol) for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Diminished short- and long-term variability. 4. Accelerations after contractions.A nurse is performing Leopold maneuvers on a pregnant client presenting to the labor and delivery unit in active labor. The nurse notes the following findings: PMI right
- An internal examination of a 20 year old client revealed the following: cephalic presentation, cervix 3 cms dilated, 75% effaced, station is -1 frequency is 2-3 minutes, duration 45 seconds, moderate intensity. When asked to perform the partograph, which of the following indicates that the nurse needs further teaching?a.Latent phase of laborb. Active phase of laborc. There should be 2 contractions or more in 10 minutesd. Duration of contractions is 20 seconds or moreA client delivered 4 hours ago. The nurse assesses the client and finds the following: fundus firm at the level of the umbilicus, moderate amount of lochia rubra and midline episiotomy well approximated . The nurse understands that fourth stage nursing care for the client includes which of the following ? a. Inspection every 15 minutes during the first hours after childbirth b. Ice pack to the perineum for up to 60 minutes per application c. Instructions to avoid intercourse for at least 12 weeks d. Application of ice beginning 4 hours after deliveryCASE SCENARIO: You are assigned at the Labor and Delivery Room in your 4th Rotation in Ilocos Training and Regional Medical Center (ITRMC). Your Clinical Instructor assigned and instructed you to assists and to monitor the vital signs of the mother especially the blood pressure and the fetal heart tone of the baby.HISTORY:Cherry Blossom is a 30-year-old woman who is a G2 P0 has been admitted to labor and delivery at 39 weeks after her membranes ruptured at home. Her first baby was born vaginally 2 years ago. She was diagnosed with gestational diabetes at 28 weeks and has been on insulin during the last trimester. Her records indicate that she is carrying a single pregnancy in vertex presentation via ultra-sound. Her past medical history is uncomplicated, she has no allergies and she take no medication other than the prenatal vitamins (folic acids and Iron supplements).Her most recent vital signs minutes ago were as follows: BP 110/70, Pulse 69 beats per minute, Respiratory rate of 20…