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 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.

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?

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

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 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?

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?

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

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

Question

The physician ordered oxytocin 20 units in 1000 mL. LR to begin at 2 mU/min. What is the flow rate in mL/hr?