Chapter 14
Common Agents Used for Systemic Analgesia Antiemetics - Hydroxyzine (Vistaril) 50-100 mg IM
Does not relieve pain but reduces anxiety and potentiates opioid analgesic effects; cannot be given IV Is used to decrease nausea and vomiting
Variable decelerations
HR up or down, cord compression = VERY BAD Prolapsed cord= push head up, change mom position
A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension? -betamethasone -methylergonovine -atropine -ephedrine
ephedrine A hypotensive agent such as ephedrine is given to elevate blood pressure if hypotension occurs.
The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR by Doppler at which frequency? -every 10 minutes -every 15 minutes -every 20 minutes -every 30 minutes
every 15 minutes It is recommended that the FHR be assessed during the second stage of labor every 5-15 minutes min by Doppler or continuously by EFM.
sinusoidal pattern
is described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for more than 20 minutes. A true sinusoidal FHR pattern is rare. It is attributed to a derangement of CNS control of FHR and occurs when a severe degree of hypoxia secondary to fetal anemia and hypovolemia is present. It is always considered a category III pattern, and to correct it, a fetal intrauterine transfusion would be needed. It indicates the fetus is in marked jeopardy
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? -increased cervical dilation (dilatation) -increased feelings of control -less anxiety -decreased sedation
less anxiety Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.
Late decelerations
are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. They have a gradual waveform and can be recurrent, occurring with each contraction over a period of time. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists
Prolonged decelerations
are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes. The rate usually drops to less than 90 bpm. Many factors are associated with this pattern, including prolonged cord compression, abruptio placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, maternal seizures, regional anesthesia, or uterine rupture
A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? -encouraging the woman to push when she has a strong desire to do so -alleviating perineal discomfort with the application of ice packs -palpating the woman's fundus for position and firmness -completing the identification process of the newborn with the mother
encouraging the woman to push when she has a strong desire to do so During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.
deceleration
is a transient fall in FHR caused by stimulation of the parasympathetic nervous system. Decelerations are described by their shape and association to a uterine contraction. They are classified as early, late, and variable only
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control? -meperidine -thiopental -hydroxyzine hydrochloride -secobarbital
meperidine Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the opioid or reduce anxiety.
Common Agents Used for Systemic Analgesia Opioids - Nalbuphine (Nubain) 10-20 mg IV
-Is given IV -Causes less maternal nausea and vomiting -Causes decreased FHR variability, fetal bradycardia, and respiratory depression
When assessing the effectiveness of the obstetrical regional analgesia received by a client, the nurse recognizes it is successful by the complete loss of pain sensation at which level of the spinal cord? -below T8 level -below T7 level -below T6 level -below T5 level
below T8 level Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord.
Common Agents Used for Systemic Analgesia Antiemetics - Prochlorperazine (Compazine) 5-10 mg IV or IM
Frequently given with morphine sulfate for sleep during prolonged latent phase; counteracts the nausea that opioids can produce
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? -"An injury is unlikely because of expert professional care given." -"I have never read or heard of this happening." -"The injection is given in the space outside the spinal cord." -"The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."
"The injection is given in the space outside the spinal cord." An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.
GUIDELINES FOR ASSESSING FHR
-Initial 10- to 20-minute continuous FHR assessment upon entry into labor and birth area Completion of a prenatal and labor risk assessment on all clients -Intermittent auscultation every 30 minutes during active labor for a low-risk woman and every 15 minutes for a high-risk woman -During the second stage of labor, every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage
Common Agents Used for Systemic Analgesia Opioids - Butorphanol (Stadol) 1-2 mg IV
-Is given IV Q 2-4 hr -Is rapidly transferred across the placenta -Causes neonatal respiratory depression
Common Agents Used for Systemic Analgesia Opioids- Fentanyl (Sublimaze) 50-100 mcg IV
-Is given IV or epidurally -Can cause maternal hypotension, maternal and fetal respiratory depression -Rapidly crosses placenta
Common Agents Used for Systemic Analgesia Benzodiazepines - Diazepam (Valium) 2-5 mg IV
-Is given to enhance pain relief of opioid and cause sedation -May be used to stop eclamptic seizures -Decreases nausea and vomiting -Can cause newborn depression; therefore, lowest possible dose should be used
Common Agents Used for Systemic Analgesia Benzodiazepines-Midazolam (Versed) 1-5 mg IV
-Is not used for analgesic but amnesia effect -Is used as adjunct for anesthesia -Is excreted in breast milk
Common Agents Used for Systemic Analgesia Antiemetics - Promethazine (Phenergan) 25-50 mg IV or IM
-Is used for antiemetic effect when combined with opioids -Causes sedation and reduces apprehension -May contribute to maternal hypotension and neonatal depression
The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? -90 to 140 bpm -100 to 150 bpm -110 to 160 bpm -120 to 170 bpm
110 to 160 bpm The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? -Acceleration of at least 15 bpm for 15 seconds -Increase in variability by 27 bpm -Deceleration followed by acceleration of 15 bpm -Decrease in variability for 15 seconds
Acceleration of at least 15 bpm for 15 seconds A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.
Analysis of Amniotic Fluid
Amniotic fluid should be clear when the membranes rupture. Rupturing of membranes is either spontaneous or artificial by means of an amniotomy, during which a disposable plastic hook (an Amnihook) is used to perforate the amniotic sac. Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.
How does a woman who feels in control of the situation during labor influence her pain? -Feelings of control are inversely related to the client's report of pain. -Decreased feeling of control helps during the third stage. -There is no association between the two factors. -Feeling in control shortens the overall length of labor.
Feelings of control are inversely related to the client's report of pain. Studies reveal that women who feel in control of their situation are apt to report less pain than those who feel they have no control.
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? -Risk factors -Maternal status -Fetal status -Maternal obstetrical history
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.
preventing meconium aspiration syndrome.
If it is determined that meconium-stained amniotic fluid is due to fetal hypoxia, the maternity and pediatric teams work together to prevent meconium aspiration syndrome, which can lead to respiratory distress. This would necessitate suctioning after the head is born before the infant takes a breath and perhaps direct tracheal suctioning after birth if the Apgar score is low. In some cases, an amnioinfusion (introduction of warmed, sterile normal saline or Ringer's lactate solution into the uterus) is used to dilute moderate to heavy meconium released in utero
uteroplacental insufficiency
Inability of the placenta to exchange oxygen, carbon dioxide, nutrients, and waste products properly between the maternal and fetal circulations.
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist? -Dry, cracked lips -Urinary retention -Rapid progress of labor -Inability to push
Inability to push If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.
A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? -Alert the team that internal fetal monitoring may be needed. -Palpate the area just above the symphysis pubis. -Institute effleurage and apply pressure to the client's lower back during contractions. -Encourage the client to push.
Palpate the area just above the symphysis pubis. Palpate just above the symphysis pubis to determine if the infant is engaged and to determine the presenting part of the infant; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.
The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize? -Past obstetrical history -Fetal status -Signs that birth is imminent -Client's temperature
Signs that birth is imminent The priority is to establish the imminence of the birth, then the fetal status. The obstetrical history can wait until after the birth of the baby, if necessary. The maternal blood pressure is a higher priority over the temperature to rule out possible preeclampsia.
The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients? -Clean the woman's perineum with a Betadine scrub. -Strictly follow universal precautions. -Replace soiled drapes and linen as needed. -Thoroughly wash the hands before and after client contact.
Thoroughly wash the hands before and after client contact. The most important infection control technique in any health care setting is thoroughly washing hands on a routine basis. Keeping the area clean is secondary but also important.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? -Help the woman to sit up in a semi-Fowler's position. -Turn her or ask her to turn to her side. -Administer oxygen at 3 to 4 L by nasal cannula. -Ask her to pant with the next contraction.
Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.
At what time is the laboring client encouraged to push? -When the nurse wants the client to push -When the health care provider has arrived -When the cervix is fully dilated -When the fetal head can be seen
When the cervix is fully dilated To avoid birth trauma, the client is not encouraged to push until the cervix is fully dilated. This is determined on vaginal exam. Once it is noted, there is no need to wait until the fetal head can be seen. The urge to push may be present without full cervix dilation. Labor is not stopped until the health care provider arrives. A nurse can deliver the fetus.
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? -application of vibroacoustic stimulation -tactile stimulation -administration of oxygen by mask -fetal scalp stimulation
administration of oxygen by mask The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation.
Periodic baseline changes
are temporary, recurrent changes made in response to a stimulus such as a contraction. The FHR can demonstrate patterns of acceleration or deceleration in response to most stimuli.
accelerations
are transitory abrupt increases in the FHR above the baseline that last less than 30 seconds from onset to peak. They are associated with sympathetic nervous stimulation. They are visually apparent, with elevations of FHR of more than 15 bpm above the baseline, and their duration is longer than 15 seconds but less than 2 minutes
Early decelerations
are visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They rarely decrease more than 30 to 40 bpm below the baseline. head compressions.
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: -acupressure. -patterned breathing. -therapeutic touch. -effleurage.
effleurage Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.
Neuraxial analgesia/anesthesia
is the administration of analgesic (opioids) or anesthetic (capable of producing a loss of sensation in an area of the body) agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain. Low-dose and ultra-low-dose epidural analgesia, spinal analgesia, and combined spinal-epidural analgesia have replaced the traditional epidural for labor. Neuraxial analgesia does not interfere with the progress or outcome of labor. There is no need to withhold neuraxial analgesia until the active stage of labor
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: -right upper quadrant. -right lower quadrant. -left upper quadrant. -left lower quadrant.
left lower quadrant. The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.
Baseline fetal heart rate
refers to the average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes. The normal baseline FHR ranges between 110 and 160 beats per minute (bpm)
A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client? -accidental intrathecal block -respiratory depression -postdural puncture (spinal) headache -a failed block
respiratory depression Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.
While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? -tachypnea and a widening pulse pressure -tachycardia and a falling blood pressure -bradycardia and auscultation of fluid in the base of the lungs -bradypnea and hypertension
tachycardia and a falling blood pressure Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs.
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first? -Assess for labor progression. -Prepare the client for an epidural. -Assist the client in ambulating to the bathroom. -Instruct the client to do slow-paced breathing.
Assess for labor progression. Performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the client experience a reduction in pain. However, the best first step is to assess the client for labor progress before assisting her otherwise. Bearing down can be a sign that the client is 10 cm dilated.
The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client? -Massage therapy -Continuous labor support -Pharmacologic pain management -Prenatal classes
Continuous labor support Continuous labor support by a caring nurse or doula can help decrease a woman's anxiety during labor. Anxiety causes the release of catecholamines, which slow down the labor process. The continuous support helps keep the woman focused on what is important as well as provide necessary guidance and education as needed. The massage therapy, prenatal classes, and pharmacologic pain management are all tools that the nurse can use to help the woman.
The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? -Engagement of fetus -Dilation (dilatation) of cervix -Rupture of amniotic membranes -Bloody show
Dilation (dilatation) of cervix The best determination of effective contractions is dilation (dilatation) of the cervix. Engagement, membrane rupture, and bloody show may all occur before the cervix has dilated.
Common Agents Used for Systemic Analgesia Opioids - Morphine 2-5 mg IV
-May be given IV or epidurally -Rapidly crosses the placenta, causes a decrease in -FHR variability -Can cause maternal and neonatal CNS depression -Decreases uterine contractions
Common Agents Used for Systemic Analgesia Opioids - Meperidine (Demerol) 25-75 mg IV
-May be given IV, intrathecally, or epidurally with maximal fetal uptake 2-3 hr after administration -Can cause CNS depression -Decreases fetal variability
Four specific criteria must be met for continuous internal monitoring to be used:
-Ruptured membranes -Cervical dilation of at least 2 cm -Presenting fetal part low enough to allow placement of the scalp electrode -Skilled practitioner available to insert spiral electrode
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. -Turn the client on her left side. -Reduce intravenous (IV) fluid rate. -Administer oxygen by mask. -Assess client for underlying causes. -Ignore questions from the client.
-Turn the client on her left side. -Administer oxygen by mask. -Assess client for underlying causes. The nurse should turn the client on her left side to increase placental perfusion, administer oxygen by mask to increase fetal oxygenation, and assess the client for any underlying contributing causes. The client's questions should not be ignored; instead, the client should be reassured that interventions are to effect FHR pattern change. A reduced IV rate would decrease intravascular volume, affecting the FHR further.
The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize? -Call the anesthetist from the nurse's station to retry the epidural. -Call the primary care provider, and obtain a reduced dose of meperidine. -Give the meperidine because she needs pain relief now. -Encourage her through the contractions, explaining why she cannot receive any pain medication.
Encourage her through the contractions, explaining why she cannot receive any pain medication. At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.
A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure? -To prevent supine hypotension syndrome -To decrease the heart rate of the fetus -To aid the woman as she pushes during labor -To prevent the woman from falling out of bed
To prevent supine hypotension syndrome The term "rhythm strip testing" means assessment of the fetal heart rate for whether a good baseline rate and long- and short-term variability are present. For this, help a woman into a semi-Fowler position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent her uterus from compressing the vena cava and causing supine hypotension syndrome during the test. Placing her in this position does not decrease the heart rate of the fetus. It is not done to aid the woman as she pushes in labor, as she is not in labor yet. It is not done to prevent her from falling out of bed.
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? -variable decelerations -prolonged decelerations -early decelerations -accelerations
prolonged decelerations Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth? -"The baby is coming. Relax and everything will turn out fine." -"Do you want me to call in your family?" -"Even though the baby is coming, the health care provider will be here soon." -"The baby is coming. I'll explain what's happening and guide you."
"The baby is coming. I'll explain what's happening and guide you." Continuous labor support with a trained nurse or doula has been shown to be effective in increasing coping ability of laboring woman. To keep her calm, the nurse needs to explain all procedures and discuss all events to the mother. The nurse cannot know the final outcome and should be careful of making general statements indicating everything will be OK. It is the nurse's responsibility to calm the client down and not wait for the health care provider. While calling the family may help, there is no guarantee and the nurse needs to work to calm the client down.
A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do? -Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. -Agree with the client, and administer the drug immediately to keep the pain manageable. -Explain to the client that opioids should only be administered an hour or less before birth. -Refuse to administer opioids because they can develop dependency in the client and the fetus.
Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. The timing of administration of opioids in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, opioids are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.
There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? -Women report higher levels of satisfaction when regional anesthetics are used to control pain. -Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. -Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. -Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain.
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Women identify being involved in their pain management and adequate control of their pain as important factors in their overall labor experience. Women often report that it is not the amount of pain they have during labor that contributes to a satisfactory birth experience but rather how their pain is managed.
Leopold maneuvers
a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the nurse's hands with the fingers together palpate the uterus. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question: -Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? -Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) -Maneuver 3: What is the presenting part? -Maneuver 4: Is the fetal head flexed and engaged in the pelvis?