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 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 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 in labor. Which process will the nurse use to determine the duration of contractions?

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

The nurse is caring for a laboring client with early decelerations and a fetal heart rate baseline of 130 with moderate variability. What will the nurse do for this client?

The nurse takes a phone call from a client at two weeks postpartum. The client states, "My left breast hurts." What other question will the nurse ask her to determine if it is mastitis?

The nurse is caring for a client at 42 weeks' gestation arriving for an induction of labor. The provider is planning to use dinoprostone (Cervidil) vaginal insert for cervical ripening. What is the nurse's priority prior to insertion?

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?

A postpartum client has continuous seepage of bright red blood from the vagina. The nurse completes an assessment and finds a firm uterus, 1 cm below the umbilicus, and midline. What does the nurse suspect is the reason for the bleeding?