Chapter 14: Nursing Management During Labor and Birth (Prep U)

A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response? "The pain relief offered will compensate for the discomfort afterward." "The anesthesiologist will do her best to avoid this." "Spinal headache is not a usual complication of epidural blocks." "Your health care provider knows what is best for you."

"Spinal headache is not a usual complication of epidural blocks." Because epidural anesthesia does not enter the cerebral spinal fluid space, it is unlikely to cause a "spinal headache."

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? Notify the registered nurse. Wait 2 minutes to review another tracing. Notify the health care provider. Assess and reposition the woman.

Assess and reposition the woman. Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team? Observatory to assist the RN Provide care under the supervision of an RN Assist the providers in the delivery room Provide direct independent care to the client

Provide care under the supervision of an RN The LPN may provide care within the appropriate scope of practice under the direct supervision of an RN. The RN is responsible for providing direct independent care of the client. Both LPN/LVNs and RNs assist health care providers in the delivery room. The LPN/LVNs provide more than just observatory functions for the RN.

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Leopold maneuver Urinalysis Vaginal examination Nonstress test

Vaginal examination A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.

All pain management modalities can slow labor if given too early except: epidural anesthesia hydrotherapy acupuncture narcotics

acupuncture Acupuncture can be used to augment labor. Epidural anesthesia and narcotics such as meperidine and butorphanol can slow labor progress if given too early.

As a woman enters the second stage of labor, which would the nurse expect to assess? reports of feeling hungry and unsatisfied expressions of satisfaction with her labor progress feelings of being frightened by the change in contractions falling asleep from exhaustion

feelings of being frightened by the change in contractions The nature of contractions changes so drastically— the urge to push is very strong—that this can be frightening.

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: left lower quadrant. right upper quadrant. left upper quadrant. right 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.

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 causes the release of endorphins." "It distracts your brain from the sensations of pain." "It disrupts the nerve signal of pain via mechanical irritation of the nerves."

"It distracts your brain from the sensations of pain." Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.

A nurse is assessing a female client in the labor admission unit. The client has been having contractions every 5 minutes for the past 6 hours. Which finding would the nurse use to determine if the client is experiencing true labor? The client's membranes ruptured spontaneously. The cervix has changes of effacement and dilation (dilatation). The client has a history of giving birth to two infants. The contractions increase in duration and intensity.

The cervix has changes of effacement and dilation (dilatation). True labor is only indicated when the cervix has changes in dilation and effacement. Delivering previous infants, an increase in intensity and duration of contractions, and the rupture of membranes do not mean that cervical changes have taken place.

In providing culturally competent care to a laboring woman, which is a priority? Identify the decision maker within the family. Identify any cultural foods used prior to labor. Identify how the client expresses labor pain. Identify who is the support person during the labor.

Identify how the client expresses labor pain. Pain is a part of the labor process and management of the pain impacts the labor process itself. The nurse must effectively be able to assess the client's pain level to be able to provide care. Individuals from different cultures express pain in different ways. All of the other options are important to understand but they do not directly relate to the client and birth process.

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.

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? thiopental meperidine 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 narcotic or reduce anxiety.

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? Ask the client who she would like to see first Print a copy of the instructions for the doula to sign Determine what activities the doula is qualified to handle Continue with the admission assessment

Continue with the admission assessment The nurse should continue with the assessment to establish a baseline for the client and determine her status. This could include asking any personal questions that might be inappropriate to ask in front of the doula. Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A doula does not take the place of a nurse or client's partner but is there to assist in the process. There would be no need to print off any instructions for the doula to sign.

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. Monitor vital signs. Assess the amount of cervical dilation (dilatation).

Assess the amount of cervical dilation (dilatation). If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation (dilatation). Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response? Ask the husband to gently remind her of their goal of natural birth and to encourage and help her. Suggest a less extreme alternative such as a sedative. Gently remind the client of her goal of a natural birth and encourage and help her. Support the client's decision and call the obstetrician.

Support the client's decision and call the obstetrician. Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: "Effleurage is the pattern for cleaning the perineum before birth." "Effleurage is light abdominal massage used to displace pain." "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening." "Effleurage is the effect of a full bladder on fetal descent."

"Effleurage is light abdominal massage used to displace pain." Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor.

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies? "How do you want the health care team to plan your care?" "Picking from these options, what options do you feel is best?" "Tell me how you handled labor pain in your past deliveries." "Who do you want to be with you when you are in labor?"

"Tell me how you handled labor pain in your past deliveries." When the nurse is collecting data, it is best to discuss previous experiences with labor pain. Other questions may include, "What was helpful?" or "What did you not like?" While it is true that every labor is different, understanding the client's perspective from past experiences is valuable in developing individualized strategies. Developing a plan is best as a collaborative effort, not by picking pre-prepared options. It is important to include a support person if desired.

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best? "The analgesia will reduce the sensation of pain for a limited period of time." "The analgesia will limit your ability to be out of bed without assistance." "The analgesia will block pain sensation and limit your ability to push." "The analgesia will allow for a pain-free birth experience."

"The analgesia will reduce the sensation of pain for a limited period of time." It is best to prepare the client for the role of analgesia in her labor experience. It is best to explain that analgesia will reduce, not block or eliminate, the pain sensation for a limited period of time depending upon the medication selected. Stating the inability to get out of bed does not answer the client's question about pain relief.

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? "Do you want me to call in your family?" "The baby is coming. I'll explain what's happening and guide you." "The baby is coming. Relax and everything will turn out fine." "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." 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.

An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification? "I changed the client position from her back to her side." "I instructed the client to ring if she felt the need to move her bowels." "The client is experiencing lower back pain and I gave a backrub." "The client reports a pain level of 8. She has a low pain tolerance."

"The client reports a pain level of 8. She has a low pain tolerance." Shift handoff includes a report of the client's pain assessment. Pain is a perceptive experience as individual pain tolerances vary. The nurse must do a complete pain assessment and not assume that the client has a low pain tolerance. Pain is an indication that a complication of labor is occurring. All of the other options are appropriate.

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? "I have never read or heard of this happening." "An injury is unlikely because of expert professional care given." "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.

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching? "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it." "If you end up having a cesarean, the epidural can be used for anesthesia during surgery." "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." "You have no trouble walking around and using the bathroom after you receive the epidural."

"You have no trouble walking around and using the bathroom after you receive the epidural." Epidural anesthesia impairs mobility; most clients are placed on bed rest after epidural anesthesia is given. Urinary catheterization is frequently required.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? 6.5 5.5 5.0 6.0

6.5 Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data? A urine dipstick test to check for protein A urine culture to rule out a urinary tract infection A blood culture to note any infection of the blood An ultrasound to determine fetal age

A urine dipstick test to check for protein Due to client symptoms suggesting preeclampsia, a urine dipstick test will screen for proteinuria. Proteinuria is commonly found in clients with preeclampsia. There are no other symptoms of an infection in the blood or a urinary tract infection requiring this diagnostic test. An ultrasound may be utilized at some point.

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? Decrease in variability for 15 seconds Increase in variability by 27 bpm Deceleration followed by acceleration of 15 bpm Acceleration of at least 15 bpm 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.

A client is reporting considerable postpartum abdominal and perineal pain at a 7 on a scale of 1 to 10. The nurse will prioritize which action after noting the client is currently receiving ibuprofen 600 mg every 8 hours? Apply a cold pack to the perineum. Assist the client to change position. Administer acetaminophen with codeine. Offer a hot pad for the abdomen.

Administer acetaminophen with codeine. Ibuprofen (600 to 800 mg) may be ordered to be given every 6 to 8 hours around the clock. This type of dosing is often more effective at keeping pain under control than is an "as-needed" schedule; however, a combination medication, such as acetaminophen with codeine, may be ordered on an as-needed basis for breakthrough pain. Applying either a hot pad or cold pack or changing positions are nonpharmacologic approaches which may be used to help with the pain if the client does not desire to take medication. It may also lessen the amount of pain medication that is needed to control the client's pain.

A client in labor has requested the administration of narcotics 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? Explain to the client that narcotics should only be administered an hour or less before birth. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. Refuse to administer narcotics because they can develop dependency in the client and the fetus. Agree with the client, and administer the drug immediately to keep the pain manageable.

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 narcotics 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, narcotics 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.

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? Assist the client in ambulating to the bathroom. Prepare the client for an epidural. Instruct the client to do slow-paced breathing. Assess for labor progression.

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.

A client has just received combined spinal epidural. Which nursing assessment should be performed first? Assess for spontaneous rupture of membranes. Assess for fetal tachycardia. Assess for progress in labor. Assess pain level using a pain scale. Assess vital signs.

Assess vital signs. The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.

A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize? Immediately report to the RN that the FHR shows no variability. Immediately report to the RN that the FHR shows tachycardia. Before reporting to the RN, determine the uterine contraction pattern. Before reporting to the RN, determine the short term variability (STV).

Before reporting to the RN, determine the uterine contraction pattern. The nurse needs to assess and determine if the changes are related to accelerations secondary to contractions. Assess the contraction pattern with the fetal heart rate and provide information to the RN. If the accelerations are not due to uterine contractions, notify the RN immediately. Until then, the nurse should do the assessment before reacting.

The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper? Yellow Pink Blue White

Blue If the fluid in the vaginal canal is amniotic fluid, the Nitrazine paper will turn a dark blue, the color of an alkaline fluid, and this is a positive Nitrazine test for rupture of membranes.

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? Continuous external monitoring of uterine contractions Intermittent monitoring of the uterine resting tone Intermittent fetal heart rate auscultation Continuous internal monitoring of uterine contractions

Continuous internal monitoring of uterine contractions Since this client has had a cesarean section, it is helpful to monitor uterine contractions, not resting tone. The nurse would follow the intensity of the contractions to avoid uterine rupture from the previous birth. External monitoring and intermittent fetal heart rate auscultation are noninvasive and not as helpful determining uterine contraction intensity.

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? Pharmacologic pain management Massage therapy Prenatal classes Continuous labor support

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 preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? Sitting in a hot tub helps decrease the need for pain medication. Continuous support through the labor process helps decrease the need for pain medication. Lying on an ice pack can help decrease the need for pain medication. A quick epidural can replace the need for pain medication.

Continuous support through the labor process helps decrease the need for pain medication. Continuous labor support involves offering a sustained presence to the laboring woman. A support person can assist and provide aid with acupressure, massage, music therapy, or therapeutic touch. Research has validated the value of continuous labor support versus intermittent support in terms of lower operative deliveries, cesarean births, and request for pain medication.

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 Rupture of amniotic membranes Engagement of fetus Dilation (dilatation) of cervix

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.

At which time in a client's labor process would the nurse encourage effleurage? At home as the client is determining true labor During the active labor phase Immediately prior to birth During the early labor phase

During the early labor phase Effleurage, a form of touch therapy, is a technique that the client uses in early labor. Light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking pain sensation. This technique does not determine true labor, is not helpful in the active stage of labor (as contractions are more intense), nor is it done when the client is ready to give birth.

Which complication occurs as a result of ineffective breathing patterns? Hyperventilation Nausea Hiccups Flatus

Hyperventilation Vigorous application of breathing techniques can lead to hyperventilation. If hyperventilation occurs, have the client breathe into cupped hands or a paper bag. Hyperventilation is directly related to the breathing pattern. The other options may occur for a variety of reasons during the labor process.

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 from 6 to 25 beats per minute. FHR fluctuates less than 5 beats per minute. FHR fluctuates over 25 beats per minute. FHR fluctuation range is undetectable.

FHR fluctuates from 6 to 25 beats per minute. Variability is described in four categories: absent, fluctuations range undetectable; minimal, fluctuations range observed at <5 beats per minute; moderate (normal), fluctuation range from 6 to 25 beats per minute; and marked, fluctuation range >25 beats per minute.

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? Fetal status Maternal status Maternal obstetrical history Risk factors

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.

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? Prepare the woman for an emergency cesarean birth. Document the finding. Help the woman change positions. Obtain assistance to check for a compressed umbilical cord.

Help the woman change positions. First, the nurse should assist the woman to change positions and try to find a position that is comfortable for the woman that relieves the compression. If the variables stop after the position change, the nurse will know that the compression has been relieved. However, if the variables continue, the nurse should try a variety of position changes, including the knee-chest position.

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 Inability to push Urinary retention Rapid progress of labor

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.

Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? Give the prescribed medication. Massage the woman's back. Encourage the woman to rest between contractions. Change the woman's position.

Massage the woman's back. Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Medication should be withheld until all nonpharmacologic treatments have been exhausted.

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. To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

Which statement is true regarding analgesia versus anesthesia? Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. Increased FHR variability is a common side effect when regional anesthesia is used. Analgesia and anesthesia perform the same function when it comes to blocking pain. Hypertension is the most common side effect when systemic analgesia is used.

Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. Systemic analgesia should be used with caution near the time of birth because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.

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 Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? The client has lost 100cc of blood from what I approximate on her clothing. The client has saturated three sanitary napkins in the past 4 hours. When ambulating the client to the bathroom, a gush of red blood was noted. The client states that she is having heavy bleeding.

The client has saturated three sanitary napkins in the past 4 hours. The best way to determine and report the amount of bleeding is by the number of sanitary napkins which have been saturated. This provides a common and measurable way to determine the approximate amount of bleeding. Stating heavy bleeding or a gush of blood is subjective. Determining the amount of bleeding from assessing stained clothing is difficult.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? The effects would wear off before birth. This may prolong labor and increase complications. This can lead to maternal hypertension. This would cause fetal depression in utero.

This may prolong labor and increase complications. Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor.

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic? The effects would wear off before delivery. This would cause fetal depression in utero. This may prolong labor and increase complications. This can lead to maternal hypertension.

This may prolong labor and increase complications. Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. At this point in labor, the fetus would not be affected by analgesia. The effects would wear off and the drug would need to be re-administered, which would increase the risk to the fetus. There is no link between maternal hypertension and analgesia.

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? Strictly follow universal precautions. Replace soiled drapes and linen as needed. Clean the woman's perineum with a Betadine scrub. 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.

Which assessment findings of the fetus during labor are normal? Select all that apply. Repeated variable decelerations Variability between 18-20 bpm Gradual increase in the fetal heart rate baseline Fetal heart baseline of 130 bpm Late decelerations

Variability between 18-20 bpm Fetal heart baseline of 130 bpm Normal patterns suggest that the fetus is tolerating the labor. Both variability between 18-20 bpm and a baseline heart rate of 130 bpm are within normal limits. Both late and repeated variable decelerations are abnormal and may require further intervention. A gradual increase in the fetal heart rate baseline can signal a distressed fetus.

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy? effleurage acupuncture biofeedback acupressure

acupressure Acupressure is the application of pressure or massage at designated susceptible body points. A common point used for a woman in labor is Co4, which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupuncture involves insertion of needles into the same body points. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for birth classes, is a classic example of therapeutic touch. Biofeedback is based on the belief that people have control and can regulate internal events such as heart rate and pain responses.

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 fetal scalp stimulation administration of oxygen by mask tactile 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.

The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. determining the position of the fetus determining the lie of the fetus determining the size of the fetus determining the weight of the fetus determining the presentation of the fetus

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus Leopold maneuvers help the nurse to determine the presentation, position, and lie of the fetus. The approximate weight and size of the fetus can be determined with ultrasound sonography or abdominal palpation.

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 Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? encouraging the woman to ambulate urging her to focus on one contraction at a time providing one-to-one support having the client breathe with contractions

encouraging the woman to ambulate Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring? relaxin progesterone prostaglandins endorphins

endorphins The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.

A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension? ephedrine atropine betamethasone methylergonovine

ephedrine A hypotensive agent such as ephedrine is given to elevate blood pressure if hypotension occurs.

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? every 20 minutes every 5 minutes every 10 minutes every 15 minutes

every 15 minutes During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

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

external electronic fetal monitoring Analysis of the FHR using external electronic fetal monitoring is one of the primary evaluation tools used to determine fetal oxygen status indirectly. Fetal pulse oximetry measures fetal oxygen saturation directly and in real time. It is used with electronic fetal monitoring as an adjunct method of assessment when the FHR pattern is abnormal or inconclusive. Fetal scalp blood is obtained to measure the pH. The fetal position can be determined through ultrasonography or abdominal palpation but is not indicative of fetal oxygenation.

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? excessive contractions of the uterus passage of the drug to the fetus increased frequency of micturition headache following anesthesia

headache following anesthesia The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition.

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: instruct the client or her partner to perform light fingertip repetitive abdominal massage. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. lead the client through a series of visualizations to aid in relaxation. press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist.

instruct the client or her partner to perform light fingertip repetitive abdominal massage. Effleurage is light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation. Controlled chest breathing is a technique used in Lamaze breathing. Pressing on trigger points is an acupressure technique.

The nurse is teaching a group of nursing students about pharmacologic interventions for pain in labor. The teaching has been effective when the students state that complications associated with epidural and spinal anesthesia include which conditions? Select all that apply. hypotension aspiration pruritis respiratory depression maternal fever

pruritis hypotension respiratory depression Hypotension is the most frequent side effect associated with epidural or intrathecal anesthesia. When narcotics are used in addition to anesthetics, pruritus is a common side effect. Respiratory depression is another possible side effect when narcotics are used for spinal and/or epidural anesthesia.

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? cervical dilation of 1 cm rupture of membranes insertion by any staff the presenting fetal part not visible

rupture of membranes The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client? maintaining the client in a supine position starting an IV and hanging IV fluids administrating IV ephedrine administrating IV naloxone

starting an IV and hanging IV fluids Prehydration with IV fluids helps to prevent the most common side effect of epidural anesthesia, which is hypotension (20%). If the client develops hypotension or respiratory depression, then IV ephedrine or IV naloxone, respectively, can be administered, but neither is preventive. Maintaining the client in a supine position is recommended for a spinal headache, which can be a side effect of epidural anesthesia but is not the most common side effect and is not preventive.

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? bradypnea and hypertension tachycardia and a falling blood pressure tachypnea and a widening pulse pressure bradycardia and auscultation of fluid in the base of the lungs

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.

To assess the frequency of a woman's labor contractions, the nurse would time: the end of one contraction to the beginning of the next. the beginning of one contraction to the beginning of the next. the interval between the acme of two consecutive contractions. how many contractions occur in 5 minutes.

the beginning of one contraction to the beginning of the next. Measuring from the beginning of one contraction to the next marks the time between contractions.