Chapter 14 PrepU

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? A. Assess fetal heart rate. B. Assess for constipation. C. Assess maternal blood pressure. D. Assess for dry mouth.

A. 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.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? A. FHR B. maternal comfort level C. fetal position D. signs of infection

A. 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.

The client may spend the latent phase of the first stage of labor at home unless which occurs? A. The client passes the bloody show B. The client experiences a rupture of membranes C. The contractions vary in length and intensity D. The client begins back labor

B. 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.

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 During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? A. Staggering gait B. Intense pain C. Difficulty breathing D. Decreased level of consciousness

C. Difficulty breathing Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign. A decreased LOC will occur later. A staggering gait or intense pain is not a primary symptom.

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

C. 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.

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is: A. 7.20. B. 7.21. C. 7.25 or more. D. 7.15 or less.

D. 7.15 or less. In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize? A. Blood pressure B. Level of consciousness C. Maternal heart rate D. Respiratory status

D. Respiratory status Opioids like fentanyl have significant effects on the client's respiratory status. This is the priority assessment because the other parameters are affected to a lesser degree.

Assessing a pregnant client in labor reveals that the client has not voided in the past 4 hours. What instruction will the nurse provide? A. "Even though you are sweating, you still need to urinate at least every hour." B. "It is important to try to urinate every 2 hours because you might not feel the urge." C. "You need to give a urine specimen each time you urinate so we can check for infection." D. "You need to get up and walk around a bit so that your bladder can get filled more fully."

B. "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. Bladder filling is not affected, and there is no need to give a urine specimen with each voiding. Insensible fluid loss does occur with sweating, but is not associated with the need for voiding every 2 hours.

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? A. Obtain urine specimen for urinalysis. B. Monitor vital signs. C. Monitor hydration status. D. Assess the amount of cervical dilation (dilatation).

D. 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.