Page 752 - Saunders Comprehensive Review For NCLEX-RN

having contractions every 3 minutes that last 45 seconds. The nurse notes
that the fetal heart rate between contractions is 100 beats per minute. Which
nursing action is most appropriate?
1. Notify the primary health care provider (PHCP).
2. Continue monitoring the fetal heart rate.
3. Encourage the client to continue pushing with each contraction.
4. Instruct the client’s coach to continue to encourage breathing
techniques.
232. The nurse is caring for a client in labor and is monitoring the fetal heart rate
patterns. The nurse notes the presence of episodic accelerations on the
electronic fetal monitor tracing. Which action is most appropriate?
1. Notify the primary health care provider of the findings.
2. Reposition the mother and check the monitor for changes in the
fetal tracing.
3. Take the mother’s vital signs and tell the mother that bed rest is
required to conserve oxygen.
4. Document the findings and tell the mother that the pattern on the
monitor indicates fetal well-being.
233. The nurse is admitting a pregnant client to the labor room and attaches an
external electronic fetal monitor to the client’s abdomen. After attachment of
the electronic fetal monitor, what is the next nursing action?
1. Identify the types of accelerations.
2. Assess the baseline fetal heart rate.
3. Determine the intensity of the contractions.
4. Determine the frequency of the contractions.
234. The nurse is reviewing true and false labor signs with a multiparous client.
The nurse determines that the client understands the signs of true labor if she
makes which statement?
1. “I won’t be in labor until my baby drops.”
2. “My contractions will be felt in my abdominal area.”
3. “My contractions will not be as painful if I walk around.”
4. “My contractions will increase in duration and intensity.”
235. Which assessment finding after an amniotomy should be conducted first?
1. Cervical dilation
2. Bladder distention
3. Fetal heart rate pattern
4. Maternal blood pressure
236. The nurse has been working with a laboring client and notes that she has
been pushing effectively for 1 hour. What is the client’s primary
physiological need at this time?
1. Ambulation
2. Rest between contractions
3. Change positions frequently
4. Consume oral food and fluids
237. The nurse is assisting a client undergoing induction of labor at 41 weeks of
gestation. The client’s contractions are moderate and occurring every 2 to 3
minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is
in place. The baseline fetal heart rate has been 120 to 122 beats per minute for

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