Ch 27 Labor and Birth

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

2. assess the baseline fetal heart rate

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 bpm for the past hour. What is the priority nursing action? 1. notify the HCP 2. discontinue the infusion of oxytocin 3. place oxygen on at 8 to 10 L/min via face mask 4. contact the client's primary support person(s) if not currently present

2. discontinue the infusion of oxytocin

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 HCP? 1. hemoglobin of 11 g/dL 2. fetal HR of 180 bpm 3. maternal pulse rate of 85 bpm 4. WBC count of 12,000

2. fetal HR of 180 bpm

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

2. rest between contractions

fetal presenting part is at -1 station

station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line

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

1. administer oxygen via face mask

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal HR between contractions is 100 bpm. Which nursing action is most appropriate? 1. notify the HCP 2. continue monitoring the fetal HR 3. encourage the client to continue pushing with each contraction 4. instruct the client's coach to continue to encourage breathing techniques

1. notify the HCP

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. supine position with a wedge under the right hip 2. trendelenburg's position with the legs in stirrups 3. prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1. supine position with a wedge under the right hip

Which assessment following an amniotomy should be conducted first? 1. cervical dilation 2. bladder distention 3. fetal heart rate pattern 4. maternal blood pressure

3. fetal heart rate pattern

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The HCP prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. less pressure on her cervix 2. decreased number of contractions 3. increased efficiency of contractions 4. the need for increased maternal blood pressure monitoring 5. the need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

3. increased efficiency of contractions 5. the need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

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 spontaneous urge to push is initiated from perineal pressure

3. the cervix is dilated completely 5. the spontaneous urge to push is initiated from perineal pressure

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determine 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"

4. "my contractions will increase in duration and intensity"

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 HCP 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

4. document the findings and tell the mother that the pattern on the monitor indicates fetal well-being

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. variability 2. accelerations 3. early decelerations 4. variable decelerations

4. variable decelerations