Chapter 11/12

A primigravida is concerned about the health of her baby and asks the nurse, What is the most common cause of death of babies, : The nurse explains that the cause of more than half of the neonatal deaths i the united states is due to what

Preterm births

What is the safest position for a woman in labor when a nurse observes a prolapsed cord

trendelenburg

Epidural anesthesia was initiated 30 minutes ago for a client in labor the nurse identifies that the fetus is experiencing late deceleration's list the following nursing actions in order of priority

2,1,3,4,5 Increase IV fluids, reposition client on her side, reasses fetal heart rate pattern, if late deceleration's persist notify the health care provider

A client is receiving an IV piggyback infusion infusion of oxytocin to augment labor the nurse identifies that there have been three contractions lasting 80 t 90 seconds that are less than 2 minutes apart there is a specific protocol that is following in response to this observations list in order of priority the nursing actions that should be taken

2,1,6,3,4,5 stop the piggyback infusion, check the fetal heart rate, determine whether the contractions have diminished, notify the health care provider, administer oxygen via face mask, document maternal/fetal responses

a pregnant woman at 39 weeks gestation arrives in the triage area of the birthing unit stating she thinks her water broke what should the nurse do first

Check the vaginal introitus for the presence of the umbilical cord

A primipara gave birth to an infant weighing 9 pounds 15 ounces (4508 g) She had a midline episiotomy and a third-degree laceration. she tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain.

The anal sphincter muscle has been injured

During a client;s labor, the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurses first intervention

Assist the client to turn the side-lying position

Despite medication a clients preterm labor continues her cervix dilates and birth appears to be inevitable which medication does the nurse anticipate will be prescribed to increase the chance of the newborns survival

Betamethasome

In the second stage of labor the nurse should plan to discourage a client from holding her breath longer than 7 seconds while pushing with each contraction what complication does this prevent

Fetal hypoxia

when the cervix of a woman in labor is dilated 9 cm she states that she has the urge to push how should the nurse respond

Have her pant-blow during contractions

At 40 weeks gestation a client is admitted to the birthing unit in early labor, she asks the nurse "why do you want me to lie on my side." What response explains the primary purpose of the side-lying position during labor

It enhances blood flow to the uterus and contractions

A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. she and her partner attended childbirth preparation classes Vaginal examination reveals the cervix at 3 cm dilation and 75% effacement, +1 station with occiput anterior and intact membranes the client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around based on the observation of the contractions and the clients knowledge of the physiology and mechanism of labor, how should the nurse respond

Its all right for you to walk as long as you feel comfortable and membranes are intact

A nurse performs Leopold maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several parts on the right side; round movable object in pubic area and cephalic prominence on the right side. Applying these findings which fetal position does the nurse identify

Left occipitoanterior (LOA)

A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning the client is bearing down and birth appears imminent what should the nurse tell the client to do.

Pant while resisting the urge to heat down

The cervix of a client in labor is fully dilated an effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contraction?

Push with her glottis open

why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor

Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia

A client in labor at 39 weeks gestation is told by the health care provider that she will need a cesarean birth the nurse reviews the clients prenatal history what preexisitng condition is the most likely reason for the cesarean birth

active genital herpes

After a client gives birth, what physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled

appearance of a sudden gush of blood

A client arrives at the client in preterm labor and terbutaline is prescribed for what therapeutic effect should the nurse monitor the client

decreased frequency and duration of contraction

During an emergency birth the fetal head is crowning on the perineum how should a nurse support the head as it is being born

distribute the fingers evenly around the head

The membranes of a client who is at 30 weeks gestation have ruptured spontaneously examination in the emergency department revealed that her cervix is 4 cm dilated and 75% effaced and the FHR is 136 beat/min she and her partner are admitted to the birthing unit what should the nurse do upon their arrival

introduces the staff nurses to the couple and try to make them feel welcome

A client is admitted to the birthing unit in active labor cervical dilation has progressed from 2 to 3 cm during an 8 hour period the health care provider determines that she has hypotonic dytocia and an infusion of oxytocin is prescribed to augment her contractions what is the most important nursing action at this time

monitoring the duration and intensity of the contractions

A client who is at 26 weeks gestation tells a nurse at the prenatal clinic that she has pain when urinating back tenderness and pin-tinged urine a diagnosis of pyelonephritis is made what is the most important nursing intervention at this time

observing for signs of preterm labor

A pregnant client with severe abdominal pain and heavy bleeding is prepared for a cesarean birth what is the priority nursing intervention

obtaining an informed consent and assessing for drug allergies

An expectant couple asks the nurse about the cause of low back pain in labor the nurse replies that this pain occurs most often when the position of the fetus is what

occiput posterior

A client at 38 weeks gestations is admitted for induction of labor her membranes ruptured 12 hours ago there are no other signs of labor which medication does the nurse anticipate will be prescribed

oxytocin

A client asks the nurse at the prenatal clinic whether she can continue to have sexual relations while pregnant what is an indication that the client should refrain from intercourse during pregnancy

premature rupture of membranes

A client is admitted to the birthing unit in active labor an amniotomy is performed what physiologic change does the nurse expect to occur after the procedure

progressive dilation and effacement

A nurse observes a laboring clients amniotic fluid and decided that it is the expected color what description of amniotic fluid supports this conclusion

straw colored clear and contains white specks

The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious during this period and asks a nurse "Do you think it is best for me to leave because I dont seem to be doing my wife much good". What is the nurses

this is hard for you let me try to help you coach her during this difficult phase

When a clients legs are placed in stirrups for birth the nurse confirms that both legs re positioned simultaneously to prevent what

trauma to the uterine ligaments

A client has been receiving Oxycontin to argument labor for what adverse reaction cause by a prolonged Oxycontin infusion should the nurse monitor the client

water intoxication