Chapter 14 - Nursing Management During Labor and Birth

What are the advantages and disadvantages of continuous electronic fetal monitoring?

Advantage - produces a continuous record of FHR, like intermittent auscultation, when gaps are likely Disadvantage - can limit maternal movement and encourages her to lie in supine position, which reduces placental perfusion

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? a. external electronic fetal monitoring b. fetal blood pH c. fetal oxygen saturation d. fetal position

a

__________ describes the irregular variations or absence of fetal heart rate (FHR) due to erroneous causes on the fetal monitor record.

artifact

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? a. local infiltration b. epidural block c. regional anesthesia d. general anesthesia

d

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next? a. prepare the client for birth b. assess the client's cervical status c notify the health care provider d. perform Leopold's maneuver

c

The nurse caring for a client in preterm labor observes abnormal fetal heart rate patterns. Which nursing intervention should the nurse perform next? a. application of vibroacoustic stimulation b. tactile stimulation c. administration of oxygen by mask d. fetal scalp stimulation

c

The __________ spines serve as landmarks for estimating the descent of the fetal presenting part and have been designated as zero station

ischial

__________ comfort measures are usually simple, safe, effective, and inexpensive to use.

nonpharmacological

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? a. respiratory rate b. temperature c. pulse d. uterine contractions

a

Fetal __________ are transitory increases in the FHR above the baseline that are associated with sympathetic nervous stimulation.

accelerations

The nurse is monitoring a pregnant client admitted to a health care center who is in the latent phase of labor. The nurse demonstrates appropriate nursing care by monitoring the fetal heart rate (FHR) with the doppler at least how often? a. every 15 to 30 minutes b. every 30 minutes c. every hour d. continuously

c

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly? a. lower quadrant of the maternal abdomen b. at the level of the maternal umbilicus c. above the level of the maternal umbilicus d. just below the maternal umbilicus

a

A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? a. determine if the client is in true or false labor b. ask if this is the client's first pregnancy c. notify the health care provider d. assess to see if the client has any drug allergies

a

A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. For which adverse effect of the drug should the nurse monitor? a. increase sedation b. newborn respiratory depression c. nervous system depression d. decreased alertness

a

A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? Select all that apply. a. spinal abnormality b. hypovolemia c. varicose veins d. coagulation defects e. skin rashes or bruises

a, b, d

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. a. uterine resting tone b. frequency of contractions c. change in temperature d. change in blood pressure e. intensity of contractions

a, b, e

A nurse is assigned to conduct an admission assessment on the phone for a pregnant client. Which information should the nurse obtain from the client? Select all that apply. a. estimated due date b. history of drug abuse c. characteristics of contractions d. appearance of vaginal blood e. history of drug allergy

a, c, d

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next? a. continue to monitor the client b. continue to massage the client's fundus c. administer oxygen to the client d. assess the client's vaginal bleeding

b

A nurse is caring for a pregnant client who is in the active phase of labor. At what interval should the nurse monitor the client's vital signs? a. every 15 minutes b. every 30 minutes c. every n 45 minutes d. every 1 hour

b

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing? a. inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds b. inhale slowly through nose and exhale through pursed lips c. punctured breathing by a forceful exhalation through pursed lips every few breaths d. hold breath for 5 seconds after every 3 breaths

b

If the nitrazine test is inconclusive, an additional test, called the __________ test, can be used to confirm rupture of membranes.

fern

What does the Apgar score assess?

heart rate; respiratory effort; muscle tone; response to irritation stimuli; color

If the woman is diabetic, it is critical to alert the newborn nursery of potential __________ in the newborn.

hypoglycemia

What are the typical signs of the second stage of labor?

increase in irritability; SROM; low grunting sounds from woman; involuntary bearing-down movements

What positions are used for the second stage of labor?

lithotomy with feet up in stirrups; semi sitting with pillows underneath knees, arms, back; lateral/side-laying with curved back and upper leg supported; sitting on birthing stool which opens up the pelvis and helps gravity; squatting that gives the woman a sense of control; kneeling

Baseline variability represents the interplay between the __________ and sympathetic nervous systems.

parasympathetic

Third-degree laceration

through the anal sphincter muscle

Fourth-degree laceration

through the anterior rectal wall

Second-degree laceration

through the muscles of the perineal body

The primary power of labor is/are __________ contractions, which are involuntary.

uterine

A pregnant client has opted for hydrotherapy for pain management during labor. Which should the nurse consider when assisting the client during the birthing processes? a .initiate the technique only when the client is in active labor b. do not allow the client to stay in the bath for long c. ensure that the water temperature exceeds body temperature d. allow the client into the water only if her membranes have ruptured

a

The nurse explains Leopold's 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 weight of the fetus e. determining the size of the fetus

a, b, c

What information should the nurse include when taking the maternal health history?

name and age; the delivering health care provider; prenatal record; past health and family history; medications; allergies; birth attendant and pediatrician; pain management

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 stages of labor? a. monitor vital signs b. assess amount of cervical dilation c. obtain urine specimen for urinalysis d. monitor hydration staus

b

`A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate changes. What intervention should the nurse preform to manage the changes? a. assist client to a supine position b. provide supplemental oxygen c. discontinue IV fluid d. turn client to her right side

b

First-degree laceration

through the skin

What is the purpose of vaginal examination during maternal assessment?

to assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status; if presentation is cephalic, the degree of fetal head flexion, fetal skull swelling or molding can also be determined

The _________ is placed over the uterine fundus in the area of greatest contractility to electronically monitor uterine contractions.

tocotransducer

The nurse reviews the prenatal record to identify risk factors that may contribute to a decrease in __________ circulation during pregnancy and/or labor.

uteroplacental

A nurse is caring for a pregnant client in labor observes that the fetal heart rate is below 110 bpm. Which intervention should the nurse perform? Select all that apply. a. turn the client on her left side b. reduce intravenous fluid rate c. administer oxygen by mask d. assess client for underlying causes e. ignore questions from the client

a, c, d