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 is completing a fundal assessment for her postpartum clients today. What will the nurse determine when assessing the fundus?

The nurse is admitting a client in the first stage of labor with active genital herpes. Which type of birth will the nurse anticipate for this client?

The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action will the nurse take to correctly assess the uterine fundus?

The nurse is caring for a client with contractions every 2-3 minutes, moderate to palpation, with a duration of 45-60 seconds. The client is having a difficult time breathing through contractions and is requesting something for pain. The client is 5 cm dilated, 80% effaced, and at a -1 station.

Which pain relief measure would be most effective for this client?

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?

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 admitting a pregnant client into the labor and delivery unit. Which findings indicate the client is in the latent phase of the first stage of labor? Select all that apply.

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 assessing four clients on the postpartum unit. Each client's uterine assessment is below. 1. The client is three days postpartum and her fundus is 3 cm below the umbilicus 2. The client is two days postpartum and her fundus is 2 cm above the umbilicus 3. The client is one day postpartum and her fundus is 1 cm below the umbilicus 4. The client delivered 8 hours ago and her fundus is at the umbilicus

Which client is experiencing uterine subinvolution?

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?