Intrapartum Period
A 32-year-old multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Which action taken by nurse promotes pain relief in the laboring client? -Direct pressure and massage to the sacral area. -Provide a warm bath. -Administer the prescribed opioid analgesic. -Assist the client with ambulation.
Direct pressure and massage to the sacral area. Explanation: Applying direct pressure and massage to the sacral area helps relieve pressure and eases the pain of labor. It is too late to administer an opioid analgesic as it can affect the newborn. Ambulation is not advised as delivery is imminent. A warm bath may be comforting but does not relieve the pressure that is causing the pain at this stage of labor.
A client with moderate pregnancy-induced hypertension (PIH) received regional anesthesia during labor and delivery. One hour after administration of the regional anesthesia, what should the nurse monitor the client for? -Hypotension -Hypertension -Seizures -Headache
Hypotension Explanation: In a client with PIH, uteroplacental perfusion may be inadequate and gas exchange may be poor. Regional anesthesia increases the risk of hypotension resulting from sympathetic blockade, possibly causing fetal and maternal hypoxia. Hypertension, seizures, and headache aren't associated with regional anesthesia.
A client in labor is prescribed an IV of 5% dextrose in lactated Ringer's solution to run at 125 mL/hour. The IV tubing delivers 10 drops per mL. At which infusion rate should the nurse set the IV? Record your answer using a whole number. --gtts/min
21 Explanation: Multiply the number of milliliters to be infused (125) by the drop factor (10). 125 x 10 = 1,250. Then divide the answer by the number of minutes to run the infusion (60). Use the following equation: 1,250/60 = 21 gtt/minute.
A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply. -Check vital signs. -Check the fundal height. -Initiate IV therapy. -Start blood transfusion. -Notify the RN.
Check vital signs. Check the fundal height. Notify the RN. Explanation: Obtaining vital signs and checking the fundus are required actions to establish the problem. The nursing process requires assessment of the problem first before any other action. Initiating IV therapy is outside the scope of practice for an LPN, as is starting a blood transfusion.
A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response? -Explain to the client that the feeling is normal during this stage. -Assist the client to the bathroom. -Give enema to help the client move the bowel. -Tell the client that you will notify the doctor.
Explain to the client that the feeling is normal during this stage. Explanation: Signs and symptoms of transition to the second stage of labor include bulging of the vaginal introitus, an increased urge to push, increased bloody show, and grunting. The client should not be assisted to the bathroom at this time as delivery is imminent. Options 3 and 4 are not appropriate interventions during a normal second stage of labor.
Cervical effacement and dilation aren't progressing for a client in labor. The health care provider orders IV administration of oxytocin. Which rationale does the nurse give the client for the close monitoring of her fluid intake and urine output? -Oxytocin causes water intoxication. -Oxytocin causes excessive thirst. -Oxytocin is toxic to the kidneys. -Oxytocin has a diuretic effect.
Oxytocin causes water intoxication. Explanation: The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizure, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake, not oxytocin. Oxytocin has no nephrotoxic or diuretic effects; in fact, it produces an antidiuretic effect.
A client in labor tells the nurse-midwife that she feels a strong urge to push. Physical examination reveals that her cervix is 5 cm dilated. Which instruction given to the client by the nurse is appropriate at this time? -Early pushing may cause edema and impede fetal descent. -You may use the birthing ball. -You can push gently to help the fetus rotate into the proper position. -Pushing at this time may cause rupture of the membranes.
You may use the birthing ball. Explanation: Pushing (bearing down) before the cervix is completely dilated may cause edema and tissue damage and impede fetal descent. Using the birthing ball aids in fetal descent and can facilitate labor. Pushing before the cervix is fully dilated will cause swelling and tearing of the cervix and not rotation of the fetus. Membranes should have ruptured already.
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress? - maternal weight gain of 30 lb (13.6 kg) -maternal age of 22 years -blood pressure of 146/94 mm Hg -treatment for syphilis at 15 weeks' gestation
blood pressure of 146/94 mm Hg Explanation: Hypertension is defined as blood pressure levels of above 140 mm Hg systolic and 90 mm Hg diastolic that are present after 20 weeks' gestation in women with previously normal blood pressure. Hypertension reduces blood flow to the placenta; it can also cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb is within the expected parameters for a healthy pregnancy. A 22-year-old client is not at increased risk for complications due to age. Syphilis that has been treated does not pose an additional risk to the fetus.
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for: -uterine inversion. -uterine atony. -uterine involution. -uterine discomfort.
uterine atony. Explanation: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.
A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation? -Ask the client about her most recent blood glucose levels. -Prepare oral hypoglycemic medications for administration during labor. -Notify the neonatal intensive care unit that the newborn of a woman with diabetes will be coming. -Prepare the client for cesarean birth.
Ask the client about her most recent blood glucose levels. Explanation: It would be most important to find out about the client's most recent blood glucose levels because this would provide information about how well her diabetes has been controlled. Oral hypoglycemic drugs are never used during labor because they cross the placental barrier, stimulate fetal insulin production, and are potentially teratogenic. Plans to admit the neonate to the neonatal intensive care unit are premature. Cesarean birth is no longer the preferred birth for clients with diabetes. Vaginal birth is preferred and presents a lower risk to the mother and fetus.
A client at 42 weeks' pregnancy is admitted to the labor and delivery unit and started on an IV infusion of oxytocin. Which action should be included in the plan of care? -Carefully titrating the oxytocin based on the client's pattern of labor -Monitoring vital signs, including assessment of fetal well-being, every 2 hours -Allowing the client to ambulate as tolerated -Informing the client that oxytocin probably won't be effective if labor doesn't begin with the onset of the infusion
Carefully titrating the oxytocin based on the client's pattern of labor Explanation: Oxytocin may require titration to be effective; therefore, it should be titrated carefully based on the client's labor pattern. Maternal blood pressure, pulse, and respirations should be monitored every 30 to 60 minutes and with every increment of the oxytocin dose. Contraction pattern and uterine resting period should be monitored every 15 minutes. The client shouldn't be allowed to ambulate. The nurse should keep the client informed of labor progress and provide emotional support to the client and her labor partner.
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What should the nurse do next? -Prepare for immediate delivery of the baby -Insert a foley catheter -Position the client on left side -Document this as normal finding
Prepare for immediate delivery of the baby Explanation: Port-wine-colored amniotic fluid isn't normal and may indicate abruptio placentae. Immediate delivery of the baby is needed. Positioning the client on the left side does not prevent abruptio placenta. Inserting a foley catheter helps decompress the bladder but does nothing for the safety of the baby and mother.
A client who's being admitted to labor and delivery has the following data collection findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which would be the priority at this time? -Placing the client in bed to begin fetal monitoring -Preparing for immediate delivery -Checking for ruptured membranes -Providing comfort measures
Preparing for immediate delivery Explanation: This question requires an understanding of station as part of the intrapartal assessment process. Based on the client's data collection findings, this client is ready for delivery, which is the nurse's top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery.
A nurse is assisting in monitoring a client who's receiving oxytocin to induce labor. The nurse would be alert for which maternal adverse reactions? Select all that apply. -hypertension -jaundice -dehydration -fluid overload -uterine tetany -Bradycardia
hypertension fluid overload uterine tetany Explanation: Maternal adverse effects of oxytocin include hypertension, fluid overload, and uterine tetany. Oxytocin's antidiuretic effect increases renal reabsorption of water, leading to fluid overload, not dehydration. Jaundice and bradycardia are adverse effects that may occur in the neonate. Tachycardia, not bradycardia, is reported as a maternal adverse effect.
The LPN is assisting the RN in the care of a client with preeclampsia. Magnesium sulfate has been prescribed. Which priority nursing action ensures the medication is administered safely? -Check blood magnesium levels. -Check maternal vital signs. Check for voiding. -Check muscle tone.
Check blood magnesium levels. Explanation: Checking magnesium levels reduces the chances of toxicity. Vital signs is not a priority action nor is checking for voiding. Checking muscle tone, while it may be necessary to do, is not a priority.
A primigravida client with severe gestational hypertension is admitted to the labor unit. She has been receiving magnesium sulfate IV for 3 hours. The latest data reveals deep tendon reflexes (DTRs) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and urine output of 20 mL/ hour. Which action would be most appropriate? -Continue monitoring the client. -Stop the magnesium sulfate infusion. -Increase the infusion rate by 5 gtt/minute. -Decrease the infusion rate by 5 gtt/minute.
Stop the magnesium sulfate infusion. Explanation: Magnesium sulfate should be withheld if the client's respiratory rate or urine output falls, or if reflexes are diminished or absent; all of which are true for this client. The client may also show other signs of impending toxicity, such as flushing and feeling warm. Continuing to monitor the client will not resolve suppressed DTRs and low respiratory rate and urine output. The client is already showing central nervous system depression because of excessive magnesium sulfate, so increasing the infusion rate is inappropriate. Impending toxicity indicates that the infusion should be stopped rather than just slowed
