145. Labor Monitoring – Late Decelerations
A nurse observes repetitive late decelerations on the fetal monitor during labor.
What is the priority nursing action?
1. Continue monitoring
2. Reposition the client laterally and apply oxygen
3. Administer oxytocin
4. Stop oxytocin, reposition, apply oxygen, and notify the provider
144. Medication – Terbutaline Side Effect
A nurse is caring for a client receiving terbutaline for preterm labor.
Which finding should be reported immediately?
1. HR of 95 bpm
2. Maternal HR of 135 bpm
3. BP of 110/70
4. Fetal HR of 140 bpm
139. Maternal Education – Danger Signs After Discharge
Which client statement indicates the need for further teaching about postpartum warning
signs?
1. “If I soak a pad in less than an hour, I’ll call the doctor.”
2. “If I feel chest pain or trouble breathing, I’ll go to the ER.”
3. “If I feel sad sometimes, I’ll rest and try to cheer up.”
4. “If I get chills and a fever, I’ll wait and see if it passes.”
138. Newborn Care – Cold Stress
Which finding indicates the newborn is experiencing cold stress?
1. Pink, acrocyanotic hands and feet
2. Hypoglycemia, mottled skin, and respiratory distress
3. Temperature of 98.1°F (36.7°C)
4. Quiet alert state
37. Postpartum Priority – Lochia Assessment
A client who is 4 hours postpartum has lochia rubra with a large clot and saturated pad in
15 minutes.
What is the nurse’s next action?
1. Offer a new pad and reassess in 1 hour
2. Notify the healthcare provider
3. Massage the fundus and assess uterine tone
4. Document the lochia amount and continue monitoring
136. Danger Signs – Maternal Hypertension
