Intrapartum
A nurse caring for a client in labor has asked her to perform Lamaze breathing techniques to avoid pain. Which should the nurse keep in mind to promote effective Lamaze-method breathing?
Remain quiet during client's period of imagery.
A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor?
"The contractions slow down when I walk around."
At which time does the nurse anticipate that the woman will need the most pain relief measures?
Active phase
A woman in labor has received a pudendal block. The nurse would assess the woman for which condition?
Decrease in maternal blood pressure
Touch and massage can be helpful during labor. Which touch and massage methods are used in labor? Select all that apply.
Effleurage Counterpressure
The nurse is caring for a laboring client who has been administered a regional block for pain management. What is the nurse's priority action?
Ensure that emergency equipment is readily available
A nurse is teaching a group of nursing students about the mechanism of labor when the fetus is in a cephalic presentation. The nurse determines the session is successful when the students correctly place the following events in which order?
Flexion Internal rotation Extension External rotation Expulsion
A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. What report by the client would lead the nurse to predict the woman is close to labor?
Nesting
At which time is it most important to monitor for umbilical cord prolapse?
After rupture of membranes
The fetus of a woman in labor is in a vertex presentation and at a -1 station. The nurse would interpret this to mean that the fetal head is:
Floating.
A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending?
Palpate the area just above the symphysis pubis.
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?
Fetal lie
The labor and delivery charge nurse is making assignments for the day. Which client should the charge nurse assign to a nurse with 6 months experience in labor and delivery?
A gravida 5 para 2 mother in active labor (B/c no complications are expected)
The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly, bright red blood gushes from the vagina. The nurse recognizes that which occurrence is the most likely cause of this postpartum hemorrhage?
A cervical laceration
A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block?
Coagulation defects Hypovolemia Spinal abnormality
A client is now in the second stage of labor. While doing the assessment, which data should the nurse prioritize?
Contraction pattern every 15 minutes
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 30 minutes
The nurse is preparing an injection of an opioid to relieve a pregnant woman's pain. As the nurse is about to give it, the client asks for a bedpan because she has to move her bowels. The nurse's best action would be to:
Hold the injection until you evaluate her labor progress.
The nurse is caring for a client having a contraction stress test. Once placing the client on the fetal monitor, it is noted that she is not currently having any Braxton Hicks contractions. If the client does not want medication to initiate contractions, which is then best to suggest?
Inducing through nipple stimulation
After 12 hours of active labor, a multipara patient at 39 weeks' gestation is only dilated 6 centimeters. Which of the following is a consideration for the nurse?
Reassess the fetal presentation and position.
Which psychosocial state is anticipated when the client enters the active phase of labor?
The client will become more quiet and introverted.
A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull that is smallest should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet?
Transverse (biparietal)
The client is asking the nurse about the various options for pain relief and requests more information about the intradermal water injection her sister had. When explaining the procedure, the nurse should point out these injections are given at which location?
Lower back
A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands that which factors are causing the extreme pain in the client?
Lower uterine segment distention Stretching and tearing of structures Dilation (dilatation) of the cervix
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?
Lower uterine segment thinning
Which is identified as the primary outcome for initiating comfort measures during the labor process?
Maintain the labor process
Which client outcome during active and transitional labor is best?
The client will practice breathing techniques during contractions.
Which statement made by the client in the early phase of labor requires clarification?
"I have been at 3 cm for hours and I am making no progress."
A multigravida client at 39 weeks' gestation has been in labor for 8 hours without much change. The last vaginal exam revealed cervix 8 cm dilated and 0 station. Which is the best response if the client asks the nurse how far the fetus has advanced in the past half hour?
"Once your labor signs change, we can find out."
Which pelvic measurement is most important for the acceptance and entrance of the fetal head during labor?
Pelvic inlet
The client reports having a rupture of membranes that occurred 24 hours ago. When assessing the client, which data is most pertinent?
Your temperature is 38.3°C (101°F). I am having green-tinged fluid discharge. I am having contractions which are 5 minutes apart. The fetal monitor states that the fetal heart rate is 186 beats/min
A client who is in the transition phase reports her pain medication last given 3 hours ago has worn off. She asks if she can have another dose of the meperidine. How should the nurse respond to the request?
"Your phase of labor makes giving another dose unsafe."
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?
Cervical dilation (dilatation)
A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment?
Fundal height measurement Membrane status Contraction pattern
An 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 multiparous woman at 39 weeks' gestation arrives at the labor and delivery unit stating that she is in labor. Upon pelvic examination, the nurse documents a softening of the cervix and 3 cm dilation. Which nursing action is best?
Have the client ambulate in the hall and recheck.
A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process?
Initiate the technique only when the client is in active labor
When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture?
Meconium-stained amniotic fluid
Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply.
Monitor maternal and fetal vital statistics every hour Report an elevated temperature over 38℃ (100.4℉) Answer questions and encourage verbalization of fears
The nurse is admitting a client who has just arrived stating she is in labor. Which fetal assessments will the nurse prioritize on the initial vaginal examination?
Presentation Position Attitude
The nurse is assisting a health care provider in inserting an epidural into a laboring mother. Completion of which nursing task helps prevent maternal hypotension?
Priming tubing for initiating a fluid bolus
A woman dilated to 10 cm and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing?
Pudendal block
The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?
Second stage
The nurse is preparing to teach a group of soon-to-be new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens?
Shoulder
On examination, the nurse determines the client is at 50% effacement. This means:
The cervical canal is 1 cm long.
The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage?
The cervix
Which change in client status suggests that labor is anticipated?
The woman can breathe easier throughout the day.
A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm?
To constrict the uterine blood vessels