The nurse is caring for a client in labor. Assessment reveals that the fetus is in a vertex presentation and at -4 station. What does the nurse determine as the position of the fetal head?

The nurse is caring for a multiparous client who has been in labor for 12 hours. The client had a spontaneous vaginal delivery 2 years ago. This was an unplanned pregnancy with someone she only knew briefly. Since finding out she was pregnant, she has been alone. Her pain is now 8/10 and she is becoming fearful that something is wrong since she has been in labor so long.

Contractions assessment:

• Contractions every 3-4 minutes
• Palpating moderate in intensity
• Lasting 45-60 seconds Cervical exam: .3 cm
• 90% effaced . -2 station
• Fetus is in a cephalic presentation.

Which component of labor is keeping the client from advancing in labor?

The nurse assesses a laboring client's cervix and states it is 6 cm dilated and 70% effaced.
The client asks what it means to be effaced. Which descriptions will the nurse include when responding to the client? Select all that apply.

The nurse is caring for a client on the postpartum unit who had a vaginal delivery with epidural anesthesia 2 hours ago. 1. The client presses the call light and tells the nurse she needs to use the bathroom 2. The nurse arrives in the client's room 5 minutes later 3.

The client is getting out of bed alone What is the best response by the nurse?

The nurse is assisting a pregnant patient into bed after the patient reports a gush of fluid from the vagina. Which action will the nurse take first?

The nurse is caring for a client during a vaginal exam by the provider. The provider informs the client that he will use the most common mechanical method to ripen her cervix prior to induction of labor. What is the method being used by the provider?

IV calculations: (rate-mL/h and gtt/min)

IV rate calculations will be rounded to nearest whole number.

.Adult calculations: the calculation will be rounded to the nearest tenth.

.Drug Calculation safety considerations:

• Examples:
  • 5 must be answered as 0.5
  • 5.0 must be answered as 5

To promote safety, a zero must be placed to the left of the decimal point in answers that are less than one. No zero is allowed to the right of the decimal point in answers that are whole numbers. Labeling is not necessary.

Question

The nurse is caring for a client in preterm labor. The physician orders magnesium sulfate to stop her contractions. The order reads 30 grams magnesium sulfate in 1000 mL of mL/hr DSW to infuse at 2 grams/hr. What will be the flow rate in mL/hr?

The nurse is caring for a client in labor receiving oxytocin. The client asks the nurse, "What is this medication for?" What is the best response by the nurse?

IV calculations: (rate-mL/h and gtt/min)

• IV rate calculations will be rounded to nearest whole number.
• Adult calculations: the calculation will be rounded to the nearest tenth.

Drug Calculation safety considerations:

• Examples:
  • .5 must be answered as 0.5
  • .5.0 must be answered as 5
• To promote safety, a zero must be placed to the left of the decimal point in answers that are less than one. No zero is allowed to the right of the decimal point in answers that are whole numbers. Labeling is not necessary

Available: drug label above. Ordered: morphine sulfate 2 mg IM

How many mL of morphine will the nurse administer?

The nurse is observing the fetal monitoring tracing pictured below. What type of deceleration will the nurse document?

The nurse notices a decreased fetal heart rate (FHR) on the fetal monitor tracing and contacts the charge nurse. The charge nurse completes a vaginal exam and can feel a portion of the umbilical cord in the vagina.

Which emergency interventions will the charge nurse implement? Select all that apply.