Ch. 15- Nursing Care of a Family During Labor and Birth

It is most likely that the practitioner would consider performing an amnioinfusion if the EFM tracing shows which of the following?

*deep variable decelerations more than 60 bpm below the baseline with every contraction* Repetitive variable decelerations with loss of variability, or ones that last longer than one minute, or dip deeper than 60 bpm below the baseline are nonreassuring.

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

*7.15 or less* In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

A client calls the health care facility stating that they are in labor. The nurse would urge the client to come to the facility if the client reports which symptom?

*moderately strong contractions every 4 minutes, lasting about 1 minute* Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

Assessment of a pregnant client reveals that she has been having frequent contractions. Which question would be helpful to ask next?

*"Are the contractions increasing in frequency and intensity?"* The nurse's next action is to assess whether the contractions signal the beginning of labor or Braxton-Hicks contractions. Braxton-Hicks contractions occur throughout pregnancy as painless uterine contractions. As labor approaches, contractions become more consistent and increase in intensity. Rating the pain of contractions can help the health care provider decide if there is a need for pain medication or an epidural. It is not as important to know when the contractions started; rather, it's the frequency at which the contractions are occurring that indicates if labor has begun. The actual physical feeling of the muscles tightening across the abdomen is not used medically to determine the beginning of labor.

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?

*Assess and reposition the woman.* Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.

A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?

*Before reporting to the RN, determine the uterine contraction pattern.* The nurse needs to assess and determine if the changes are related to accelerations secondary to contractions. Assess the contraction pattern with the fetal heart rate and provide information to the RN. If the accelerations are not due to uterine contractions, notify the RN immediately. Until then, the nurse should do the assessment before reacting.

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?

*Continue to monitor the client and the fetal heart rate..* As long as baseline remains within normal limits and the variability is good, early decelerations are benign and no further action is necessary.

Which nursing action has a negative effect on fetal descent?

*administering opioid pain medication* Opioid pain medication is known to help with the pain associated with contractions and childbirth but it is also known to slow or even stop the progression of the labor process. The opioid effect can provide the mother with a needed break and allow her to rest between contractions. The mother may lie in any position comfortable. Neither eliminating stool nor walking in the hall will slow fetal transport.

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?

*fetal status* The woman may present to the birthing suite at any phase of the first stage of labor. Therefore, it is important to assess birth imminence, fetal status, risk factors, and maternal status immediately. If birth is not imminent and the fetal and maternal conditions are stable, perform additional data collection, including the full admission health history, a complete maternal physical assessment, the status of labor and any labor, birth, and cultural preferences the woman may have.

The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time?

*have the client change position* Fetal tachycardia, decreased variability, and late decelerations are possible indications of cord compression. The first step is to ask the client to change position to see if that will take the pressure off the cord. The health care provider should be notified, especially if a change of position is ineffective. The nurse should continue to monitor the pattern continuously until the situation is changed and to evaluate the effectiveness of interventions. This could be an ominous sign indicating the need for further interventions to include cesarean delivery.

A nurse is caring for a client in her fourth stage of labor. Which assessment(s) indicates a normal physiologic change occurring during the fourth stage of labor? Select all that apply.

mild uterine cramping and shivering well-contracted uterus in the midline decreased intra-abdominal pressure decrease in the pulse rate The normal physiologic changes for which a nurse should assess during the fourth stage of labor are a well-contracted uterus in the midline of the abdomen, mild cramping pain and generalized shivering, decreased intra-abdominal pressure, and a stable blood pressure within normal limits. The pulse is usually typically slower than during labor. This may be associated with a decrease in blood volume following placental separation. An elevated pulse rate may be an early sign of blood loss.