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 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?

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?

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 is caring for a laboring client. The nurse observes that there are variable decelerations. What is the nurse's priority action?

The nurse palpates a postpartum client's fundus two hours after birth and finds it located to the right of midline and somewhat soft. What does the nurse understand about this information?

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 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?

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 caring for a client in labor and discovers late decelerations of the fetal heart rate.
What does the nurse know as the reason for this type of deceleration?