Chapter 14: Nursing Management During Labor and Bir
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? Staggering gait Decreased level of consciousness Intense pain Difficulty breathing
Difficulty breathing
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Assess fetal heart rate for fetal safety. Ask her to bear down with the next contraction. Elevate her hips to prevent cord prolapse. Test a sample of amniotic fluid for protein.
Assess fetal heart rate for fetal safety.
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? A. Refuse to administer opioids because they can develop dependency in the client and the fetus. B. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. C. Explain to the client that opioids should only be administered an hour or less before birth. D. Agree with the client, and administer the drug immediately to keep the pain manageable.
B. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.
The nurse is caring for a client who is a gravida 2 para 1 and had a previous cesarean section. The client has had no complications with the pregnancy and prefers to have this delivery vaginally. Which monitoring system best assesses for the ability to delivery vaginally? Intermittent monitoring of the uterine resting tone Continuous internal monitoring of uterine contractions Continuous external monitoring of uterine contractions Intermittent fetal heart rate auscultation
Continuous internal monitoring of uterine contractions
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 Inability to push Rapid progress of labor
Inability to push
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 T6 level below T5 level below T7 level below T8 level
below T8 level
As a woman enters the second stage of labor, which would the nurse expect to assess? expressions of satisfaction with her labor progress feelings of being frightened by the change in contractions falling asleep from exhaustion reports of feeling hungry and unsatisfied
feelings of being frightened by the change in contractions
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypotension and fetal bradycardia maternal hypertension and fetal bradycardia maternal hypertension and fetal tachycardia maternal hypotension and fetal tachycardia
maternal hypotension and fetal bradycardia
In the labor and delivery unit, which is the best way to prevent the spread of infection? Limit vaginal examinations Complete hand hygiene Use sterile gloves Provide clean gloves in the room
Complete hand hygiene
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Vaginal examination Nonstress test Urinalysis Leopold maneuver
Vaginal examination
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? Sit on the edge of the bed with her feet dangling before ambulating. Remain in bed for at least 30 minutes. Ambulate only with assistance from the nurse or caregiver. Ambulate within 15 minutes to prevent spinal headache.
Ambulate only with assistance from the nurse or caregiver.
As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? Test a sample of amniotic fluid for protein. Elevate her hips to prevent cord prolapse. Assess fetal heart rate for fetal safety. Ask her to bear down with the next contraction.
Assess fetal heart rate for fetal safety.
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? "It blocks the transmission of nerve messages of pain at the receptors." "It disrupts the nerve signal of pain via mechanical irritation of the nerves." "It distracts your brain from the sensations of pain." "It causes the release of endorphins."
"It distracts your brain from the sensations of pain."
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? Thoroughly wash the hands before and after client contact. Clean the woman's perineum with a Betadine scrub. Replace soiled drapes and linen as needed. Strictly follow universal precautions.
Thoroughly wash the hands before and after client contact.
A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using? abdominal imagery pain pathway blockage effleurage massage
effleurage
Which intervention would be least effective in caring for a client who is in the active phase of labor? urging the client to focus on one contraction at a time encouraging the client to ambulate having the client breathe with contractions providing one-to-one support
encouraging the client to ambulate
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide? A. release of endorphins in response to the uterine contractions B. lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels C. blocking of nerve transmission via mechanical irritation of nerve fibers D. distraction of the brain cortex by other stimuli occuring in the body
B. lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels
A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: A. "Effleurage is the pattern for cleaning the perineum before birth." B. "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening." C. "Effleurage is the effect of a full bladder on fetal descent." D. "Effleurage is light abdominal massage used to displace pain."
D. "Effleurage is light abdominal massage used to displace pain."
Which documentation in the health record is most correct for the third stage of labor? A. Begins with the time of placental delivery and ends when the health care provider is satisfied that there are no placental fragments. B. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus. C. Begins with the time of placental delivery and ends 48 hours later. D. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.
D. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.
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? Bloody show Dilation (dilatation) of cervix Engagement of fetus Rupture of amniotic membranes
Dilation (dilatation) of cervix
As a woman enters the second stage of labor, which would the nurse expect to assess? falling asleep from exhaustion expressions of satisfaction with her labor progress feelings of being frightened by the change in contractions reports of feeling hungry and unsatisfied
feelings of being frightened by the change in contractions
Which client statement is anticipated after immediately receiving an intrathecal injection of pain medication? "I feel a dull achiness around my abdomen." "I still have intense pain. The medication is not working." "I have no pain now." "I feel cramping but no sharp pain."
"I have no pain now."
During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used. -4 station 0 station +4 station -2 station +2 station
-4 station -2 station 0 station +2 station +4 station
The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. A. determining the presentation of the fetus B. determining the position of the fetus C. determining the lie of the fetus D. determining the size of the fetus E. determining the weight of the fetus
A. determining the presentation of the fetus B. determining the position of the fetus C. determining the lie of the fetus
The nurse is reviewing the nursing care plan with a woman during a prenatal visit. What action(s) in the plan is to decrease the woman's pain level during labor? Select all that apply. A. using a nonpharmacologic method along with needed pharmacologic methods B. explaining the process and procedures to decrease anxiety and apprehension C. maintaining the same intervention throughout the laboring process D. continuous labor support by a doula or trained nurse E. discussion about pain relief measures prenatally
A. using a nonpharmacologic method along with needed pharmacologic methods B. explaining the process and procedures to decrease anxiety and apprehension D. continuous labor support by a doula or trained nurse E. discussion about pain relief measures prenatally
The nurse's note (above) was documented by the client's labor nurse minutes after epidural initiation. What action should the nurse take first? Offer IV ondansetron. Assess blood pressure. Initiate 500 ml IV fluid bolus.
Assess blood pressure.
During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor? Obtain urine specimen for urinalysis. Monitor hydration status. Assess the amount of cervical dilation (dilatation). Monitor vital signs.
Assess the amount of cervical dilation (dilatation).
A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: A. lead the client through a series of visualizations to aid in relaxation. B. instruct the client or her partner to perform light fingertip repetitive abdominal massage. C. press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist. D. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale.
B. instruct the client or her partner to perform light fingertip repetitive abdominal massage.
A client has just received combined spinal epidural. Which nursing assessment should be performed first? A. Assess for spontaneous rupture of membranes. B. Assess pain level using a pain scale. C. Assess vital signs. D. Assess for fetal tachycardia. E. Assess for progress in labor.
C. Assess vital signs.
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? Notify the primary care provider. Increase her IV fluids. Administer oxygen. Change the position of the client.
Change the position of the client.
The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response? Print a copy of the instructions for the doula to sign Determine what activities the doula is qualified to handle Ask the client who she would like to see first Continue with the admission assessment
Continue with the admission assessment
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? Prenatal classes Pharmacologic pain management Continuous labor support Massage therapy
Continuous labor support
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? A. Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. B. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain. C. Women report higher levels of satisfaction when regional anesthetics are used to control pain. D. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
D. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
A client at 39 weeks' gestation presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? Determine if the client is in true or false labor. Ask if this is the client's first pregnancy. Notify the healthcare provider. Assess to see if the client has any drug allergies.
Determine if the client is in true or false labor.
While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents? FHR fluctuates over 25 beats per minute. FHR fluctuation range is undetectable. FHR fluctuates from 6 to 25 beats per minute. FHR fluctuates less than 5 beats per minute.
FHR fluctuates from 6 to 25 beats per minute.
How does a woman who feels in control of the situation during labor influence her pain? Feeling in control shortens the overall length of labor. There is no association between the two factors. Feelings of control are inversely related to the client's report of pain. Decreased feeling of control helps during the third stage.
Feelings of control are inversely related to the client's report of pain.
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? Have the client lightly push to meet the need. Assist the client to a Fowler position. Have the client pant and blow through the contraction. Have the client divert the energy to squeezing a hand.
Have the client pant and blow through the contraction.
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? Help the woman change positions. Prepare the woman for an emergency cesarean birth. Document the finding. Obtain assistance to check for a compressed umbilical cord.
Help the woman change positions.
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? Contact the primary care provider. Time the contractions. Auscultate the fetal heart tones. Inspect the perineum.
Inspect the perineum.
A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? Palpate the mother's radial pulse at the same time. Have the woman lie completely flat on her back while auscultating. Ask the woman to hold her breath while assessing the FHR. Instruct the woman to bend her knees and flex her hips.
Palpate the mother's radial pulse at the same time.
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? Providing a paper bag Rubbing the client's legs Massaging the client's lower back Placing a wedge under the hips
Placing a wedge under the hips
A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? Administering a sedative such as secobarbital or pentobarbital Administering an opioid such as meperidine or fentanyl Practicing effleurage on the abdomen Immersing the client in warm water in a pool or hot tub
Practicing effleurage on the abdomen
A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement? Provide emotional and physical support. Administer the drug naloxone. Assist in preparation for a cesarean birth. Assist in providing epidural anesthesia
Provide emotional and physical support.
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize? Level of consciousness Respiratory status Blood pressure Maternal heart rate
Respiratory status
The client may spend the latent phase of the first stage of labor at home unless which occurs? The client begins back labor The client experiences a rupture of membranes The contractions vary in length and intensity The client passes the bloody show
The client experiences a rupture of membranes
Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? The father's coaching role may be disrupted at times. The mother may have difficulty working effectively with contractions. The infant may show increased drowsiness. The mother may have continued memory loss postpartum.
The mother may have difficulty working effectively with contractions.
The pain of labor is influenced by many factors. What is one of these factors? The woman has a high tolerance for pain. The woman is prepared for labor and birth. The woman has a high threshold for pain. The woman has lots of visitors during labor.
The woman is prepared for labor and birth.
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 prevent the woman from falling out of bed To aid the woman as she pushes during labor To decrease the heart rate of the fetus
To prevent supine hypotension syndrome
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? administration of oxygen by mask fetal scalp stimulation application of vibroacoustic stimulation tactile stimulation
administration of oxygen by mask
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? tactile stimulation fetal scalp stimulation administration of oxygen by mask application of vibroacoustic stimulation
administration of oxygen by mask
The student nurse is preparing to assess the fetal heart rate (FHR) and 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: left lower quadrant. right lower quadrant. right upper quadrant. left upper quadrant.
left lower quadrant.
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? hydroxyzine hydrochloride secobarbital thiopental meperidine
meperidine
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? variable decelerations accelerations prolonged decelerations early decelerations
prolonged decelerations
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? temperature uterine contractions respiratory rate pulse
respiratory rate
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? Ambulate only with assistance from the nurse or caregiver. Ambulate within 15 minutes to prevent spinal headache. Sit on the edge of the bed with her feet dangling before ambulating. Remain in bed for at least 30 minutes.
Ambulate only with assistance from the nurse or caregiver.
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? passage of the drug to the fetus increased frequency of micturition headache following anesthesia excessive contractions of the uterus
headache following anesthesia
Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH? 6.8 7.4 7.2 7.0
7.2
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? Auscultate the fetal heart tones. Inspect the perineum. Contact the primary care provider. Time the contractions.
Inspect the perineum.
The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring? insertion by any staff the presenting fetal part not visible rupture of membranes cervical dilation of 1 cm
rupture of membranes
A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering? antiretroviral benzodiazepine antibiotic ataractic
antiretroviral