Chapter 14: Nursing Management During Labor and Birth

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

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.

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 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.

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.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?

Difficulty breathing

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:

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.

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 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.

Which medication is administered to reverse the depressant effects of opioids?

Naloxone

To assess the frequency of a woman's labor contractions, the nurse would time:

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.

As a woman enters the second stage of labor, which would the nurse expect to assess?

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.

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?

General anesthesia General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed. Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide?

"It is important to try to urinate every 2 hours because you might not feel the urge." During labor, pressure from the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. Therefore, it is important to have the pregnant client void approximately every 2 hours during labor to avoid overfilling, because overfilling can decrease postpartum bladder tone.

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. 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.

The postpartum nurse is providing care for a client who has just given birth and had epidural anesthesia. Her vital signs are stable, her pain is a 3 on a scale of 0 to 10, and she states that she is tired. The feeling in the client's legs has returned, but she cannot lift her knees, and she has not been out of the bed. What is the most appropriate nursing diagnosis to include in the plan of care at this time?

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.

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?

"Our baby will come out face first." The fetal presentation pertains to the part of the fetus that comes through the cervix and the birth canal first. A face presentation indicates that the face presents first. The face is a large part of the head, so caution must be used.

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?

"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.

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

Analysis of the FHR using external electronic fetal monitoring is one of the primary evaluation tools used to determine fetal oxygen status indirectly.

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?

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.

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. Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?

Assess fetal heart rate. After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate. Maternal factors of decreased blood pressure, constipation, and dry mouth are of a lower priority.

The nursing instructor is conducting a class discussion on the various agents used during labor and delivery to assist the client. The instructor determines the class is successful after the students correctly choose which factor as true about the use of systemic analgesia?

Benzodiazepines enhance pain relief attained with opioids and cause sedation. Benzodiazepines enhance pain relief attained with opioids and cause sedation. Barbiturates are used in latent labor for their minor tranquilizing and sedative effects. They can also be used just before general anesthesia, if required. Ataractics are opioid agonists used to decrease anxiety, nausea, and vomiting. Opioids may be given IV, intrathecally, or epidurally.

In the labor and delivery unit, which is the best way to prevent the spread of infection?

Complete hand hygiene

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

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.

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. 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.

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?

Have the client pant and blow through the contraction. The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.

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. 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 full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?

Naloxone Naloxone is the drug used for reversal of opioids' adverse effects. If an opioid is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor.

The nurse is caring for a client who received a dose of IV sedation, given by the charge nurse, 30 minutes prior. What action is appropriate?

Remind the client to call for assistance before getting out of bed. The nurse will remind the client to call for help before getting out of bed to prevent falling from the sedation effects. The nurse would not expect sedatives to cause constipation if given for a limited time during labor. Fetal heart tones are assessed continuously to monitor for side effects of decreased fetal heart rate variability secondary to maternal sedatives. Sedatives do not relieve pain but may provide an opportunity to sleep and decreases anxiety during labor.

The client pushes and the baby's head emerges. External rotation begins, but the baby's chin is drawn back just inside the vagina. The nurse recognizes that additional providers are needed in the delivery room. What emergency protocol does the nurse call?

Shoulder dystocia When the fetal head is delivered but the baby's chin is drawn back just inside the vagina, that is commonly referred to as the "turtle sign" or evidence of shoulder dystocia. A shoulder dystocia emergency is called to get additional providers and equipment to the delivery room immediately. There is no evidence of fetal macrosomia or cephalopelvic disproportion in this situation. A nuchal cord would be felt and resolved by the health care provider completing the delivery.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

This may prolong labor and increase complications. Administration of pharmacologic agents such as narcotics 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.

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?

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.

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. 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.

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?

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.

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?

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.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips.