Page 750 - Saunders Comprehensive Review For NCLEX-RN

Table 23-2

Factors of the Bishop Score

Practice Questions

224. The nurse is caring for a client in labor. Which assessment findings indicate
to the nurse that the client is beginning the second stage of labor? Select all
that apply.
1. The contractions are regular.

2. The membranes have ruptured.

3. The cervix is dilated completely.

4. The client begins to expel clear vaginal fluid.
5. The Ferguson reflex is initiated from perineal pressure.

225. The nurse in the labor room is caring for a client in the active stage of the first
phase of labor. The nurse is assessing the fetal patterns and notes a late
deceleration on the monitor strip. What is the most appropriate nursing
action?
1. Administer oxygen via face mask.
2. Place the mother in a supine position.
3. Increase the rate of the oxytocin intravenous infusion.
4. Document the findings and continue to monitor the fetal patterns.
226. The nurse is performing an assessment of a client who is scheduled for a
cesarean delivery at 39 weeks of gestation. Which assessment finding
indicates the need to contact the primary health care provider (PHCP)?
1. Hemoglobin of 11 g/dL (110 mmol/L)
2. Fetal heart rate of 180 beats per minute
3. Maternal pulse rate of 85 beats per minute
3
9
4. White blood cell count of 12.000/mm (12 × 10 /L)
227. The nurse is reviewing the record of a client in the labor room and notes that
the primary health care provider has documented that the fetal presenting
part is at the −1 station. This documented finding indicates that the fetal
presenting part is located at which area? Refer to figure.

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