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 in labor. Assessment findings: The fetal heart rate (FHR) baseline is 120 bpm The FHR begins slowing as the contraction starts, and is back to baseline at the end of the contraction There is moderate variability of the FHR Which periodic change will the nurse document in the electronic health record?

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

The nurse is caring for a client in labor. Which assessment finding will the nurse report to the charge nurse immediately?

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: see drug label above Ordered promethazine 12.5mg IM

How many mL of promethazine will the nurse administer?

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.

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?

A nurse is providing care for a client experiencing postpartum hemorrhage. Which medications may be prescribed by the provider? 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 has received shift report for five clients admitted in labor. Which clients will the nurse anticipate delivering by a cesarean section? Select all that apply.