chapter 16 labor and delivery prep u

the nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

engagement

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? Ask the woman to hold her breath while assessing the FHR. Instruct the woman to bend her knees and flex her hips. Have the woman lie completely flat on her back while auscultating. Palpate the mother's radial pulse at the same time.

Palpate the mother's radial pulse at the same time.

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations.

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 light abdominal massage used to displace pain."

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

"It distracts your brain from the sensations of pain."

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements? "Transverse lie is the same as when the shoulder presents to the birth canal." "Breech presentation is when the fetal buttocks present to the birth canal." "Transverse lie is the same as when the fetal buttocks present to the birth canal." "In most pregnancies at term the fetus presents head down."

"Transverse lie is the same as when the fetal buttocks present to the birth canal."

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care?

A woman may spend time thinking about what is happening to her.

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? Remain in bed for at least 30 minutes. Ambulate within 15 minutes to prevent spinal headache. Ambulate only with assistance from the nurse or caregiver. Sit on the edge of the bed with her feet dangling before ambulating.

Ambulate only with assistance from the nurse or caregiver.

A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response? Ask the client to describe the intensity of her pain on a scale of 0 to 10. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication. Assist the client with breathing and imagery techniques in an attempt to calm her down.

Ask the client to describe the intensity of her pain on a scale of 0 to 10.

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 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?

Dilation (dilatation) of cervix

The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth? Fetus in partial extension with brow presenting to birth canal Fetus in complete extension with back arched Chin in moderately flexed military position Head flexed forward so much that the chin touches the sternum

Head flexed forward so much that the chin touches the sternum

The nurse is caring for a patient in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this patient's discomfort? Place in the Trendelenburg position. Place in a prone position. Massage the lower back. Apply ice packs to the lower back.

Massage the lower back.

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 nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. Turn the client on her left side. Ignore questions from the client. Reduce intravenous (IV) fluid rate. Assess client for underlying causes. Administer oxygen by mask.

Turn the client on her left side. Assess client for underlying causes. Administer oxygen by mask.

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? is "male" shaped has weaker bones than normal is narrow transversely is ideal for birth

is narrow transversely

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? buttocks shoulders brow occiput

occiput

When educating a group of nursing students about the different types of pelves, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type? gynecoid android anthropoid platypelloid

platypelloid

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?

sudden gush of dark blood from the vagina

A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means? Reassuring; it is associated with normal acid-base balance. Worrisome; it may be associated with metabolic acidosis. Damaging; it is frequently associated with fetal neurological damage.

Reassuring; it is associated with normal acid-base balance.

A nurse is assisting with the birth of a newborn. The fetal head has just emerged. Which action would be performed next? clamping of the umbilical cord drying of the newborn suctioning of the mouth and nose checking for the cord around the neck

checking for the cord around the neck

A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor? decrease in circulation and perfusion to the fetus increase in fetal breathing movements increase in fetal oxygen pressure decrease in arterial carbon dioxide pressure

decrease in circulation and perfusion to the fetus

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 thiopental secobarbital meperidine

meperidine

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor? shortening of the upper uterine segment reduction in length of the cervical canal effacement and dilation (dilatation) of the cervix restoration of blood flow to uterus and placenta

restoration of blood flow to uterus and placenta

The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? do nothing, this is benign palpate for bladder fullness reposition the client on either side notify the health care provider

reposition the client on either side

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. Notify the health care provider. Assess and reposition the woman. Wait 2 minutes to review another tracing.

Assess and reposition the woman.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Administer oxygen at 3 to 4 L by nasal cannula. Help the woman to sit up in a semi-Fowler's position. Ask her to pant with the next contraction. Turn her or ask her to turn to her side.

Turn her or ask her to turn to her side.

Which of the following would be a danger signal for a woman in labor? meconium-stained amniotic fluid maternal pulse of 90 to 95 beats per minute fetus presenting in an LOA position blood-tinged vaginal discharge at full dilation (dilatation)

meconium-stained amniotic fluid

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

nalaxone

A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement? "Continuous labor support can result in better labor outcomes." "Nurses can influence birth outcomes in a positive way." "Anxiety can speed up the labor process." "Anxiety can slow down the labor process."

"Anxiety can speed up the labor process."

A primigravida who is 40 weeks' pregnant thinks she may be in labor. She calls the nurse and reports that she has had 10 contractions in the last hour. She says that they are mildly painful and last 45 seconds. What is the best response from the nurse? "You should wait 1 hour, and then come to the hospital." "You need to come in right away because you live 20 minutes away." "Did your water break? Do you feel the baby moving?" "Wait until your water breaks, and then come into the hospital." "Wait 1 hour and see how the contractions change, and then call back."

"Did your water break? Do you feel the baby moving?"

The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? "She is doing well and is in the second stage; it could be anytime now." "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." "She is in active labor; she is progressing at this point and we will keep you posted." "She is still in early latent labor and has much too long to go to tell when she will give birth."

"She is in active labor; she is progressing at this point and we will keep you posted."

The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? 0 to 2 8 to 10 5 to 7 3 to 4

8 to 10

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? Agree with the client, and administer the drug immediately to keep the pain manageable. Refuse to administer opioids because they can develop dependency in the client and the fetus. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. Explain to the client that opioids 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.

Which documentation in the health record is most correct for the third stage of labor? Begins with the time of placental delivery and ends when the healthcare provider is satisfied that there are no placental fragments. Begins with the time of placental delivery and ends 48 hours later. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus.

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 laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? Change the position of the client. Notify the primary care provider. Increase her IV fluids. Administer oxygen.

Change the position of the client.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? Notify the primary care provider immediately. Change the linen saver pad. Perform a vaginal exam. Check the fetal heart rate

Check the fetal heart rate.

A client at 39 weeks' gestation presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? 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.

Determine if the client is in true or false labor.

Which nursing action is applied throughout all stages of labor?

Do not allow the client to lay flat on her back for long periods.

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

Identify how the client expresses labor pain.

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? Assist the providers in the delivery room Provide direct independent care to the client Observatory to assist the RN Provide care under the supervision of an RN

Provide care under the supervision of an RN

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? Practicing effleurage on the abdomen Administering an opioid such as meperidine or fentanyl Immersing the client in warm water in a pool or hot tub Administering a sedative such as secobarbital or pentobarbital

Practicing effleurage on the abdomen

The nurse is preparing to administer an intradermal water injection to a client who is in labor. Which action should the nurse prioritize? These injections are very effective in relieving abdominal pain caused by contractions. Prepare four 1 mL syringes of 0.05 to 0.1 mL sterile water using a 25 gauge needle. Prepare two injections of 1 mL to 5 mL normal saline using a 10 mL syringe with a 25 gauge needle. Repeat the injection every 15 to 20 minutes as necessary

Prepare four 1 mL syringes of 0.05 to 0.1 mL sterile water using a 25 gauge needle.

A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply. Provide the client clear information on procedures involved. Instruct the client to begin changing the home environment. Encourage the client to have a positive reaction to pregnancy. Instruct the client to spend some time alone each day. Encourage the client to have a sense of mastery and self-control.

Provide the client clear information on procedures involved. Encourage the client to have a sense of mastery and self-control. Encourage the client to have a positive reaction to pregnancy.

The nurse is preparing materials to instruct a pregnant patient about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the patient? Regional anesthesia General anesthesia Pressure anesthesia Pudendal nerve block

Regional anesthesia

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? After walking for an hour, the contractions have not fully subsided. The contraction pains are 2 minutes apart and 1 minute in duration. The client reports back pain, and the cervix is effacing and dilating. The contraction pains have been present for 5 hours, and the patterns are regular.

The client reports back pain, and the cervix is effacing and dilating.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? the mother may have difficulty working effectively with contractions. The father's coaching role may be disrupted at times. The mother may have continued memory loss postpartum. The infant may show increased drowsiness.

The mother may have difficulty working effectively with contractions.

During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective? The patient is not requesting pain medication. The patient is focusing on a painting during contractions. The patient is not complaining of leg cramps. The patient asks for a cold compress at the end of a contraction.

The patient is not requesting pain medication.

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? This can lead to maternal hypertension. The effects would wear off before birth. This would cause fetal depression in utero. This may prolong labor and increase complications.

This may prolong labor and increase complications.

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

Vaginal examination

A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? Women should be able to move about freely throughout labor. Routine intravenous fluid should be implemented. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. A woman should be allowed to assume a supine position.

Women should be able to move about freely throughout labor.

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: transient fetal hypoxia. normal. a possible infection. meconium passage.

a possible infection.

At midpoint during pregnancy, you review beginning signs of labor with a client. One of the beginning signs of labor you would review is: sharp, right-sided abdominal pain. a sudden gush of clear fluid from the vagina. an increased pulse rate and upper abdominal pain. excessive fatigue and headache.

a sudden gush of clear fluid from the vagina.

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

During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? Select all that apply. begin and remain irregular felt first in lower back and sweep around to the abdomen in a wave often disappear with ambulation or sleep increase in duration, frequency, and intensity begin irregularly but become regular and predictable felt first abdominally and remain confined to the abdomen and groin

begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? regular contractions fetal movement through the birth canal cervical dilation (dilatation) placental separation

cervical dilation (dilatation)

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? cervical dilation (dilatation) of 2 cm or more intact membranes floating presenting fetal part a neonatologist to insert the electrode

cervical dilation (dilatation) of 2 cm or more

The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize? increased variability early decelerations decreased variability late decelerations

decreased variability

Patterned breathing techniques used in labor provide which benefits? Select all that apply.

distraction pain relief without special tools conscious relaxation

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

effleurage.

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

engagement

f 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

A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply. activity of fetus frequency intensity duration status of membranes

frequency intensity duration

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? local infiltration general anesthesia regional anesthesia epidural block

general anesthesia

n OB/GYN care provider has just finished evaluating the 100th client. If the nurse could review all the documentation from each client related thus far, which type of pelvis would the nurse predict as being identified most often by the care provider as supporting the success of a vaginal delivery?

gynecoid and anthropoid, respectively

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

instruct the client or her partner to perform light fingertip repetitive abdominal massage.

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient? latent phase active phase transition phase none of the above

latent phase

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: placenta previa. lightening. rupture of the membranes. start of labor.

lightening.

When teaching a group of pregnant women about the events occurring in the body with uterine contractions, the nurse describes what happens as labor contractions progress and become more regular. The nurse would include which change as a typical feature? uterus attaining an ovoid appearance uterus becoming more rounded in shape stronger contracting occurring in the lower segment lower uterine segment thinning

lower uterine segment thinning

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypertension and fetal tachycardia maternal hypertension and fetal bradycardia maternal hypotension and fetal bradycardia maternal hypotension and fetal tachycardia

maternal hypotension and fetal bradycardia

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which area? skin muscles of perineal body anterior rectal wall anal sphincter

muscles of perineal body

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding? poorly ossified bones of the cranial vault rigid bones at the base of the skull well-ossified bones of the face tight membranous attachments

poorly ossified bones of the cranial vault

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? variable decelerations accelerations early decelerations prolonged decelerations

prolonged decelerations

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor? decrease in duration of contractions rupture of amniotic membranes development of a membrane further closing the cervix decrease in vaginal secretions

rupture of amniotic membranes

A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor? first stage third stage fourth stage second stage

second stage

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? cephalic breech vertex shoulder

shoulder

Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply. walking with partner support straddling with forward leaning over a chair rocking back and forth with foot on chair supine with legs raised at a 90-degree angle closed knee-chest position

walking with partner support straddling with forward leaning over a chair rocking back and forth with foot on chair