Confusion

60 min 30 min 15-30 min

FHR monitoring times: Latent Active Transition

It helps to rotate fetus in a posterior position.

A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor? It helps the woman in labor to save energy. It facilitates vaginal examinations. It facilitates external belt adjustment. It helps to rotate fetus in a posterior position.

Feel for presentation, position, lie

What is the purpose of leopald manuenvers?

Secobarbital In the latent phase of labor, sedatives can be prescribed to assist a client to rest. The use of analgesics, such as opioids (meperidine, fentanyl, and morphine) in early labor may stop labor and are not recommended.

A client in latent labor for the past 12 hours is requesting medication to help her rest. The nurse predicts the health care provider will prescribe which medication? Secobarbital Meperidine Fentanyl Morphine

a. infection c. abrupt placenta d. prolapse cord e. umbilical cord compression

During Amniotomy, what will the patient be at risk for after the procedure? Select all that apply. a. infection b. placenta previa c. abruptio placenta d. prolapse cord e. umbilical cord compression f. uterine rupture

lack of variability late deceleration fetal tachycardia

During possible fetal distress that involves lack of _____________________,______________________,____________________simply changing the woman's position is inadequate. The nurse should notify the health care provider immediately regarding the situation. Select all that apply. a. fetal bradycardia b. fetal tachycardia c.early deleceration d. late deceleration e. lack of variability f. marked variability e. minimal variability

Blood pressure Once the epidural catheter is inserted, blood pressure readings are obtained by the nurse every 3 to 5 minutes due to the potential side effect of hypotension. The other options are important to assess but not as directly related to the epidural or as important to monitor as the blood pressure.

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority? Temperature Pain level Respiratory rate Blood pressure

Active

With every client encounter: self-absorbed in labor; intense and quiet now Latent Active Transition

Extension As the fetus progresses down the birth canal, flexion coaxes the fetus to assume the position of the smallest diameter of the fetal head to fit through the dimension of the pelvis. Extension and external rotation occur later in the labor process before birth and passes the fetal head through the pubic arch to birth of the head. Engagement occurs when the fetal head descends to the level of the ischial spines and can occur 2 weeks prior to the initiation of labor.

Which cardinal movement allows the fetus to travel through the birth canal most efficiently? Extension External rotation Flexion Engagement

Descent Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines. Descent continues throughout labor until the fetus reaches the fetal station of +4. The other options represent fetal movements to accommodate the passage of the fetus.

Which cardinal movement of delivery is the nurse correct to document by station? Descent Flexion Extension Internal rotation

Maintain the labor process All of the outcomes are accurate but the primary outcome is to maintain the labor process. By relaxing the mother, it is easier for her to work with her body and facilitate the labor process.

Which is identified as the primary outcome for initiating comfort measures during the labor process? Improve the psyche of the mother Increase client satisfaction Maintain the labor process Acknowledge pain during childbirth

history of maternal diabetes dates indicating a post-term pregnancy measurements indicating fetal macrosomia

A client in labor has been diagnosed with shoulder dystocia. Which risk factors would the nurse expect in the prenatal history? Select all that apply. documented intrauterine growth restriction maternal cervical insufficiency history of maternal diabetes dates indicating a post-term pregnancy measurements indicating fetal macrosomia

"The fetal head is in an abnormal position." A deceleration phase has become prolonged when it extends beyond 1 hour in a multipara. A prolonged deceleration phase most often results from abnormal fetal head position. Usually the size of the fetal head and shoulders have been measured via ultrasound and considered adequate to descend before labor. If the fetus turned to a breech position, a cesarean birth would have been scheduled. The woman's bladder can be emptied via catheter while she is in bed, so this should not be the problem.

A multipara woman is fully dilated and effaced and has been pushing for over 2 hours. The student nurse observing asks the nurse, "What is causing this to last so long?" Which response by the nurse would be the most accurate? "The fetal head and shoulders are too large to get through the canal." "The fetal head is in an abnormal position." "The fetus probably turned to a breech position at the last minute." "The woman's bladder is too full, so the fetus cannot descend."

estimated due date characteristics of contractions appearance of vaginal blood When conducting an admission assessment on the phone for a pregnant client, the nurse needs to obtain information regarding the estimated due date, characteristics of contractions, and appearance of vaginal blood to evaluate the need to admit her. History of substance use or a drug allergy is usually recorded as part of the client's medical history.

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

• Decreased intra-abdominal pressure • Well-contracted uterus in the midline • Mild uterine cramping and shivering Explanation: The normal physiologic changes for which a nurse should assess during the fourth stage of labor are a well-contracted uterus in the midline of the abdomen, mild cramping pain and generalized shivering, and decreased intra-abdominal pressure. Hemodynamic changes are due to normal blood loss during delivery, causing moderate tachycardia and a slight fall in the blood pressure during the fourth stage of labor. A fall in the pulse rate and increased blood pressure are not normal findings occurring during the fourth stage of labor.

A nurse is caring for a client in her fourth stage of labor. Which of the following assessments would indicate normal physiologic changes occurring during the fourth stage of labor? Select all that apply. a) Well-contracted uterus in the midline b) Decrease in the pulse rate c) Mild uterine cramping and shivering d) Decreased intra-abdominal pressure e) Increase in the blood pressure

Renewed bearing down efforts by client • Fresh gushing of blood from the vagina • Umbilical cord descending lower down Correct Explanation: The signs of placental separation include a fresh gush of blood from the vagina, lengthening of the umbilical cord, and renewed bearing-down efforts by the client. When the client is in her third stage of labor, these indicate placental separation. A rising upwards of the uterus and a well-contracted globular uterus are the other signs of placental separation. Falling downward of the uterus in the abdomen and a relaxed uterus are the signs of uterine atony.

A nurse is caring for a client in her third stage of labor. Which of the following would the nurse assess as indicating placental separation? Select all that apply. a) Renewed bearing down efforts by client b) Fresh gushing of blood from the vagina c) Falling downward of uterus in the abdomen d) A relaxed and distended uterus e) Umbilical cord descending lower down

uterine atony A complication of general anesthesia is the relaxation of the uterine muscles, leading to uterine atony and possible postpartum hemorrhage. Maternal hypotension, a failed block, and pruritus are side effects of epidural analgesia.

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication? maternal hypotension inadequate pain block pruritus uterine atony

every 30 minutes When a pregnant client is in the active phase of labor, the nurse should monitor the vital signs every 30 minutes. The nurse should monitor the vital signs every 30 to 60 minutes if the client is in the latent phase of labor and every 15 to 30 minutes during the transition phase of labor. Temperature is usually monitored every 4 hours in the active phase of labor.

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

need for someone to control the situation

A nurse is conducting a presentation for a group of pregnant women about labor and the importance of being well prepared and having good labor support. The nurse determines that additional discussion is needed when the group identifies which possible outcome as the result of being prepared? need for someone to control the situation less likely to need analgesia less likely to need anesthesia unlikely to require cesarean birth

Sudden onset of respiratory distress Maternal hypotension Maternal tachycardia

A nurse is presenting an in-service program about complications that can arise during labor. The nurse determines that the teaching was successful when the group correctly chooses which findings as suggesting an amniotic fluid embolism? Select all that apply. Sudden onset of respiratory distress Slow onset of fetal distress Maternal hypotension Maternal tachycardia Acute, continuous abdominal pain

Maneuvers for fetal positioning Before labor induction is started, fetal maturity (dating, ultrasound, amniotic fluid studies) and cervical readiness (vaginal examination, Bishop scoring) must be assessed. Both need to be favorable for a successful induction. Maneuver's to determine fetal position (Leopold's maneuver) is a technique done as the fetus moves through the labor process.

A nurse is teaching a 42-week nulliparous pregnant woman about labor induction which is being recommended by her health care provider. The nurse determines that the woman needs additional teaching when she identifies which assessment as being done before induction? Maneuvers for fetal positioning fetal dating Bishop scoring amniotic fluid studies

Check perineal area frequently for bleeding. precipitate dilation (dilatation) is cervical dilation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara. Contractions can be so forceful they lead to premature separation of the placenta or lacerations of the perineum, placing the woman at risk for hemorrhage. The other interventions are appropriate, but the priority is assessing for bleeding/hemorrhage.

A woman arrives in the L & D unit in the beginning early phase with her contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the woman in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the woman for which priority assessment caused by a rapid birth? Assess bladder for fullness. Check perineal area frequently for bleeding. Assess the woman's breathing and intervene if necessary. Assess and administer pain medication as needed.

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.

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

In the active phase of the first stage of labor The most pain medication is given during the active phase of labor. Implementing general comfort measures with narcotic analgesia or epidural anesthesia is common. During the transition phase, the woman's contractions become intense and include an urge to push. A goal for this period is that the woman's pain will be manageable. Comfort measures are most important as narcotics are not given at this advanced stage. Luckily, this phase is typically the shortest. The latent phase is the early portion of labor. This is frequently completed at home with comfort measures provided by the support person. The second stage of labor begins with full dilation (dilatation) and ends with the birth.

At which time does the nurse anticipate that the woman will need the most pain relief measures? In the latent phase of the first stage of labor At the beginning of the second stage of labor During the transition phase of the first stage of labor In the active phase of the first stage of labor

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.

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 early labor phase During the active labor phase Immediately prior to birth

Flexion Explanation: As the head descends during labor, the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. This resistance normally coaxes the fetus to assume an attitude of flexion. Flexion is the attitude that presents the smallest diameters of the fetal head to the dimensions of the pelvis.

During a spontaneous vaginal birth several things need to occur to the fetus in sequence. As the fetus encounters resistance, what is its usual reaction? a) Flexion b) Extension c) Internal rotation d) Engagement

Fetal heart rate at the peak of a contraction Normal labor stresses the fetus by increasing intracranial pressure, decreasing heart rate and placental blood flow. Assessing the fetal heart rate during the peak of the contraction best indicates how the fetus is tolerating the labor. Fetal movement and fetal kicks can indicate that a fetus is compromised but that is a late sign of distress.

In which manner is the fetal status best assessed during the active and transition stages of labor? Fetal heart rate at the peak of a contraction Fetal movement on the tocometer Fetal heart rate between contractions Fetal kicks over a 1-minute period

The primigravida who has a thinning cervix and a dilation of 3 cm The primigravida who is not fully effaced with a low (3 cm out of 10) dilation (dilatation) will be sent home. At this point, it is unclear if the client is in true or false labor. Multiparous women typically have shorter labors, thus the nurse must consider this fact when anticipating health care provider decisions. The primigravida who is effaced and dilated 6 cm is definitely in labor even if the contractions are at irregular intervals.

The nurse is caring for four clients within the labor and delivery unit. Which client does the nurse anticipate will be sent home? The primigravida who is effaced, having intense contractions but at irregular intervals and dilation (dilatation) is 6 cm The multipara who just experienced lightening and is having contractions 7 minutes apart. The primigravida who has a thinning cervix and a dilation of 3 cm The multipara who is effaced with dilation of 4 cm.

a 44-year-old primipara diagnosed with gestational diabetes in active labor for the past 6 hours a 33-year-old female who is 32 weeks' gestation in labor with twins a 30-year-old multipara woman who has experienced premature rupture of membranes 5 days ago but is just now reporting it to the health care provider Augmentation or initiation of labor carries risks; it must be used cautiously in women with multiple gestation, polyhydramnios, grand parity, or those who are older than 40 years. Prolonged rupture of the membranes might make induction necessary before the usual 39 weeks' gestation period. Four hours of active labor is a normal occurrence. An 18-year-old woman in labor experiencing acute pain is also a normal occurrence.

The nurse manager is reviewing all the L & D clients on the unit in order to prepare assignments to the nursing staff. For which clients would augmentation of labor with oxytocin be considered contraindicated or used cautiously? Select all that apply. a 27-year-old primipara in active labor for the past 4 hours a 44-year-old primipara diagnosed with gestational diabetes in active labor for the past 6 hours a 33-year-old female who is 32 weeks' gestation in labor with twins an 18-year-old primipara client who is experiencing acute pain and refusing an epidural catheter a 30-year-old multipara woman who has experienced premature rupture of membranes 5 days ago but is just now reporting it to the health care provider

Crowning Correct Explanation: Crowning occurs when the top of the fetal head appears at the vaginal orifice and no longer regresses between contractions. Engagement occurs when the greatest transverse diameter of the head passes through the pelvic inlet. Descent is the downward movement of the fetal head until it is within the pelvic inlet. Restitution or external rotation occurs after the head is born and free of resistance. It untwists, causing the occiput to move about 45 degrees back to its original left or right position.

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which of the following? a) Descent b) Engagement c) Restitution d) Crowning

Use fingers to press upward on the presenting part.

The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation (dilatation). Assessment reveals a prolapsed umbilical cord. Which action should the nurse prioritize? Turn client to her left side. Place client in a knee-chest position. Use fingers to press upward on the presenting part. Prep for immediate cesarean delivery.

a. b. e. g.

What are indications for a patient to be induce? Select all that apply. a. Spontaneous rupture of the membrane near term b. chorioamnionitis c. umbilical cord prolapse d. Abnormal presentation e. fetal compromise (IUGR) f. non reassuring heart rate patterns g. hypertension h. previous uterine incision

a. c. d. e.

What are risk for a patient who has been induced or augment? Select all that apply. a. uterine rupture b. fetal tachycardia c. uterine tachsystole d. cesarean birth e. water intoxication

W/ absent variability b. fetal bradycardia c. recurrent late decelerations e. recurrent variable decelerations f. sinusoidal pattern

What are the components for Non reassuring patterns in Category III. Select all that apply a. fetal tachycardia b. fetal bradycardia c.Recurrent late decelerations d. Minimal or marked variability e. Recurrent variable decelerations f. Sinusoidal pattern g. Absent variability with no recurrent deceleration

c. slowed progress e. inadequate strength

What are the indications for a patient to have augmentation? Select all that apply. a. Postterm b. fetal death c. slowed progress d. hypertension e. inadequate strength f. fetal compromise

a. gush of blood b. Cord descents further into the vagina e. uterus rises upward f. uterus becomes spherical

What are the signs that the placenta is separating from the uterine wall? Select all that apply. a. gush of blood b. Cord descents further into the vagina c. Cord is unnoticeable d. Uterus is downward e. Uterus rises upward f. Uterus becomes spherical/ globule g. Uterus becomes flat

1. Engagement - fetal head meets largest part 2. Descent- Contractions descend the head downwards 3. Flexion- baby head flex to the smallest diameter 4. Internal Rotation- to get the largest part of the head out 5. Extension- The head falls back passes pubs symphysis 6. External Rotation- to get the shoulders out 7. Expulsion - the whole body is out

What is the order of the cardinal movements.

Do not allow the client to lay flat on her back for long periods. Throughout the labor process, the client is not to lay flat on her back due to supine hypotension. This places weight on the great vessels and decreases blood flow. It is acceptable to place a pillow or wedge under one hip, thus distributing the client's weight to one side. The client may do the other options at different points throughout the labor process.

Which nursing action is applied throughout all stages of labor? Discourage the client from ambulating after the rupture of membranes. Do not allow the client to lay flat on her back for long periods. Place the client on nothing by mouth (NPO) status while in labor. Limit the client to have no more than one support person in the labor room.