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INTRAPARTUM NCLEX QUESTIONS WITH CORRECT ANSWERS

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1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A. The client begins to expel... clear vaginal fluid B.The contractions are regular C.The membranes have ruptured D.The cervix is dilated completely Correct Answer 1.4. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate. A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of Pitocin IV infusion Correct Answer 3. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous Pitocin infusion is discontinued when a late deceleration is noted. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? 1.Fetal heart rate of 180 beats per minute 2.White blood cell count of 12,000 3.Maternal pulse rate of 85 beats per minute 4.Hemoglobin of 11.0 g/dL Correct Answer 1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hem dilution caused by an increase in plasma volume during pregnancy. A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: 1.Trendelenburg's position with the legs in stirrups 2.Semi-Fowler position with a pillow under the knees 3.Prone position with the legs separated and elevated [Show More]

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