Intrapartum Period
Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? "Do you have any chronic illnesses?" "Do you have any allergies?" "What is your expected due date?" "Who will be with you during labor?"
"What is your expected due date?"
A laboring client on oxytocin is becoming more vocal and is voicing increased pain with the uterine contractions. The nurse performs a fetal and maternal assessment and finds that the uterus is not relaxing between contractions. Based on the assessment findings which of the following would be the best action for the nurse? Increase the oxytocin until uterine contractions exceed 80 seconds duration. Continue the oxytocin until uterine contractions are more frequent than every 2-3 minutes. Discontinue the oxytocin if the uterus does not relax between uterine contractions. Administer pain medicine for reports of increasing discomfort.
Discontinue the oxytocin if the uterus does not relax between uterine contractions.
An emergency cesarean birth is planned for a pregnant client who begins to experience excessive vaginal bleeding soon after admission. When developing this client's plan of care, which action would be the priority? Shave the abdomen and perineal area. Ask family members to wait in the waiting room. Assess the status of the fetus. Ensure availability of replacement blood.
Ensure availability of replacement blood.
A client who is 5 cm dilated reports that she has the urge to push. Which is the appropriate response by the nurse? Encourage the client to push with the next contraction. Administer additional pain medication. Have client blow out breath to keep from pushing. Prepare the client for a cesarean section.
Have client blow out breath to keep from pushing.
The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply. IV hydration maternal position change oxygen administration epidural pain medication increased oxytocin infusions
IV hydration maternal position change oxygen administration
The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent? Patterns of verbal communication Religious beliefs Influence of the extended family Gender identity
Influence of the extended family
The nurse waits for the placenta to deliver. Which action should the nurse take? Ask the client to push down forcefully. Massage the fundus firmly. Observe for signs of placental separation. Reach into the uterus with sterile gloves.
Observe for signs of placental separation.
Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation? breech position transverse lie occiput posterior position compound presentation
breech position
While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions? duration, frequency, and intensity dilation, duration, and frequency frequency, duration, maternal position dilation, effacement, position
duration, frequency, and intensity
To determine whether a primigravid client in labor with a fetus in the left occiput anterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination, the nurse should palpate which cranial sutures? sagittal lambdoidal coronal frontal
sagittal
A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response? "This is a routine assessment and your baby is fine." "The baby has had a bowel movement, indicating severe fetal distress." "The baby needs to be observed more closely." "The baby has had a bowel movement, indicating mild fetal distress."
"The baby needs to be observed more closely."
A client who's a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. Cervical examination is likely to reveal the client is 2 cm dilated; 100% effaced at 0 station. 4 to 5 cm dilated; 80% effaced at -1 station. 2 cm dilated; 50% effaced at +1 station. 3 cm dilated; 50% effaced at 0 station.
2 cm dilated; 100% effaced at 0 station.
A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, the client's membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first? Increase the rate of the oxytocin infusion. Turn the client to a knee-to-chest position. Assess cervical dilation and effacement. Assess the fetal heart rate.
Assess the fetal heart rate.
A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: X-linked recessive and the disease will only occur if the baby is a boy. X-linked dominant and there is no likelihood of the baby having cystic fibrosis. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.
Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.
The nurse hears a pregnant client yell, "Oh my! The baby is coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is being born. What should the nurse do first? Suction the mouth with two fingertips. Check for presence of a cord around the neck. Tell the client to bear down with force. Advise the mother that help is on the way.
Check for presence of a cord around the neck.
The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply. Increase the oxytocin infusion. Contact the healthcare provider. Administer oxygen to the client. Discontinue the external fetal heart monitor. Change the client's position.
Contact the healthcare provider. Administer oxygen to the client. Change the client's position.
The nurse is caring for a pregnant client. The nurse notes hypotension and a non-reassuring fetal heart tracing. Which action would the nurse include in the client's plan of care? Position the client on her left side. Have the client empty her bladder. Encourage the client to hold her breath. Call the health care provider.
Position the client on her left side.
The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what action should the nurse take next? Have the client push with a contraction. Ask the client to take a deep breath and hold it. Prepare an area to receive the neonate. Lower the head of the bed to a flat position.
Prepare an area to receive the neonate.
The nurse caring for the laboring client performs a sterile vaginal exam. Exam results are dilated 10 cm, effaced 100%, and +2 station. What is the priority nursing intervention? Initiate oxytocin infusion. Call anesthesia to give epidural anesthesia. Prepare for birth of the neonate. Assess for rupture of the membranes.
Prepare for birth of the neonate.
The nurse is caring for a client who is attempting a trial of labor (attempt a vaginal birth after cesarean). Contractions are 1.5 minutes apart with a duration 75 to 90 seconds. The client reports a "sharp, tearing" pain, and the electronic fetal monitor (EFM) is no longer recording contractions. What is the priority nursing action? Perform a sterile vaginal exam (SVE). Prepare the client for an emergency cesarean birth. Insert an intrauterine pressure catheter. Reposition the client.
Prepare the client for an emergency cesarean birth.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor? Breathe slowly after each contraction. Avoid the use of analgesics for labor pain. Remain in a side-lying position with the head elevated. Request local anesthesia for vaginal birth.
Remain in a side-lying position with the head elevated.
A low-risk multigravid client is in active labor and has begun pushing. The fetal head is beginning to crown. What action should the nurse take to prevent perineal lacerations during birth? Stretch the perineal tissues with sterile gloved fingers. Hold the fetal head back with a sterile gloved hand. Tell the client to stop pushing during the next two contractions. Ask the client to hold their breath while pushing during the entire contraction.
Stretch the perineal tissues with sterile gloved fingers.
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed oxytocin intravenously after delivery of the placenta. Which sign would indicate to the nurse that the placenta is about to be delivered? The cord lengthens outside the vagina. There is decreased vaginal bleeding. The uterus cannot be palpated. The uterus changes to a discoid shape.
The cord lengthens outside the vagina.
A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply. Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client. Discuss the case with the client's mother, who is an immediate family member. Discuss the case at lunch to educate other staff members. Keep a unit log of all clients infected with HIV for research purposes.
Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client.
What data indicates to the nurse that placental detachment is occurring? an abrupt lengthening of the cord a decrease in the number of contractions relaxation of the uterus decreased vaginal bleeding
an abrupt lengthening of the cord
Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? an increased sense of rectal pressure a decrease in intensity of contractions an increase in fetal heart rate variability episodes of nausea and vomiting
an increased sense of rectal pressure
A primigravid client at 39 weeks' gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at +1 station. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing which problem? cephalopelvic disproportion prolonged latent phase prolonged transitional phase hypotonic contraction pattern
cephalopelvic disproportion
The end of the third stage of labor is marked by what event? the birth of the neonate complete dilation delivery of the placenta transfer of the client to the postpartum bed
delivery of the placenta
A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6-cm dilated. After administration of this anesthesia, which assessment would be most important? fetal heart rate maternal pulse level of anesthesia level of consciousness
fetal heart rate
The nurse is caring for a postpartum client with an episiotomy. The nurse assesses the client closely for what complication that the client is at greatest risk of developing? blood loss urinary incontinence infection dyspareunia
infection
The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience what type of pain? no pain sharp pain light pain moderate pain
no pain
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding? passage of meconium by the fetus maternal intrauterine infection Rh incompatibility between the birth mother and the fetus maternal sexually transmitted disease
passage of meconium by the fetus
When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal system? urinary gastrointestinal cardiovascular pulmonary
pulmonary
A client in active labor asks the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse? "It is part of our standard policy." "Changes in your blood pressure can affect the fetus." "Low blood pressure may cause dizziness and fainting." "Increased blood pressure is a sign of preeclampsia."
"Changes in your blood pressure can affect the fetus."
The nurse instructs the client about the procedures that will be performed on the neonate immediately after birth to prevent meconium aspiration. The nurse determines that the instructions have been effective when the client states that which procedure will be done to her baby? "Suctioning will be needed if the baby is floppy." "A tube will be placed in the baby's nose." "The baby will be given oxygen by a mask." "The baby will be given a drug to dilate the bronchi."
"Suctioning will be needed if the baby is floppy."
A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response? "Yes, but only after you read about the procedure in the regional policy and procedure manual." "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first." "Yes, but I will demonstrate it once and then supervise you while you perform the procedure." "No, only certified registered nurses can perform this skill."
"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."
A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which rate would cause the nurse to intervene? 60-79 beats per minute 80-120 beats per minute 121-160 beats per minute 161-200 beats per minute
60-79 beats per minute
After the vaginal birth of a term neonate, the nurse determines that the placenta is about to separate when which event occurs? The uterus becomes oval shaped. The uterus enlarges. A sudden gush of dark blood appears. The client expends efforts pushing.
A sudden gush of dark blood appears.
The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed? Perform a nonstress test. Perform a sterile vaginal exam. Check the fetal heart rate for bradycardia. Prepare for an imminent birth.
Check the fetal heart rate for bradycardia.
A nurse is caring for a primigravid client at 40 weeks' gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation and fetal heart rate baseline 135 bpm, decreases to 125 bpm shortly after the onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first? Position the client on the left side, and administer oxygen via face mask. Document the findings on the client's medical record, and continue to monitor labor progress. Perform a vaginal examination to rule out umbilical cord prolapse. Notify the health care provider (HCP) immediately, and prepare for an emergency cesarean birth.
Document the findings on the client's medical record, and continue to monitor labor progress.
The nurse is caring for a client in labor. The client wishes to have a "nonmedicated" labor and birth. During the early stages of labor, the client becomes frustrated with the use of music and imagery. Which of the following would the nurse include in the client's plan of care? Select all that apply. Offer the client epidural anesthesia. Administer butorphal IV. Encourage ambulation. Suggest a shower or bath. Offer the use of a yoga ball.
Encourage ambulation. Suggest a shower or bath. Offer the use of a yoga ball.
The client and her partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence? Actions were based on the advice of a more experienced nurse. The nurse holds competencies required for nursing care. The national standards of practice were met when providing care. The healthcare provider's (HCP's) written orders were followed.
The national standards of practice were met when providing care.
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean birth? client at 40 weeks' gestation whose fetus weighs 8 lb (3630 g) by ultrasound estimate client at 37 weeks' gestation with the fetus in the right occiput posterior (ROP) position client at 32 weeks' gestation with the fetus in the breech position client at 38 weeks' gestation with active herpes lesions
client at 38 weeks' gestation with active herpes lesions
The nurse is assisting a client who just received an epidural during the first stage of labor. Which medication does the nurse know may be needed at this time? magnesium sulfate terbutaline oxytocin methergine
oxytocin
A pregnant client's labor is progressing, but the cervix is still only 5 cm dilated and 100% effaced. Although the client appears relaxed, they are aware of labor contractions. At this time, which suggestion would be most helpful for the client's partner? "Keep a record of the contraction pattern." "Encourage your partner to rest between contractions." "Suggest that your partner receive an epidural anesthetic." "Have your partner practice rapid, shallow breathing."
"Encourage your partner to rest between contractions."
A nurse is assisting in the birthing room. The healthcare provider prepares to perform a midline episiotomy. On the illustration, identify the area where the healthcare provider makes the incision.
below fetus head NOT to rectum
The nurse would question the prescription for a fetal scalp electrode on which client? client with an HIV infection client with late decelerations client with significant meconium-stained fluid client with a prolonged second stage of labor
client with an HIV infection
In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion? persistent fetal bradycardia variable decelerations fetal heart rate accelerations late decelerations
fetal heart rate accelerations
When the nurse is preparing the room for admission of a multigravida client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain? oxytocin infusion solution disposable tongue blades portable ultrasound machine padding for the side rails
padding for the side rails
A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations from 100 to 110 bpm. What should the nurse do next? Perform a vaginal examination. Notify the health care provider (HCP) of the decelerations. Reposition the client and continue to evaluate the fetal heart rate. Administer oxygen via mask at 2 L per minute.
Reposition the client and continue to evaluate the fetal heart rate.
A client's partner tells the nurse that he will remain in the waiting room while the client is in labor. The client's sister has been chosen to be her birth companion. Which of the following responses from the nurse would be most appropriate? Encourage the partner to stay with the client because, as the baby's father, he is the best birth companion. Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born. Inform the client and her partner that only fathers can stay in the birthing room. Ask the client if she agrees with her partner's desire to stay in the waiting room.
Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born.
The nurse is explaining to a primagravida in labor that the baby is in a breech presentation, with the baby's presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how the baby is positioned?
head up
A healthcare provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement? time of fetal scalp electrode placement, name of the HCP who placed the electrode, and frequency of uterine contractions time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR) the name of the HCP who applied the electrode, Doppler transducer placement, and FHR the maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR
time of fetal scalp electrode placement, name of the HCP who applied the electrode, and the fetal heart rate (FHR)
The primigravid client is at +1 station and 9 cm dilated. Based on these data, what should the nurse do first? Ask the anesthesiologist to increase epidural rate. Assist the client to push if the client feels the need to do so. Encourage the client to breathe through the urge to push. Support family members in providing comfort measures.
Encourage the client to breathe through the urge to push.
A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse? total weight gain of 30 lb (13.6 kg) maternal age of 32 years blood pressure of 146/90 mm Hg treatment for syphilis at 15 weeks' gestation
blood pressure of 146/90 mm Hg
The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use? deep kneading of superficial muscles secure grasping of muscular tissues light stroking of the skin surface prolonged pressure on specific sites
light stroking of the skin surface
During preparation for a parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions? "Walking around helps to decrease true contractions." "True labor contractions are irregular and intense." "The duration and frequency of true labor contractions remain the same." "True labor contractions are felt first in the lower back, then the abdomen."
"True labor contractions are felt first in the lower back, then the abdomen."
A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension? Administer ephedrine to raise her blood pressure. Administer oxygen using a mask. Place the woman supine with her legs raised. Ensure adequate hydration before the anesthetic is administered.
Ensure adequate hydration before the anesthetic is administered.
A client who has abruptio placentae exhibits cyanosis in the earlobes, capillary filling time >3 seconds, and reports "heartburn." Which is the best nursing intervention? Notify the healthcare provider immediately. Assess for vaginal bleeding. Increase the temperature of the room and provide warmed blankets. Elevate the head of the bed.
Notify the healthcare provider immediately.
A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates that teaching about spinal anesthesia has been understood? "The medication will be administered while I am in the prone position." "The anesthetic may cause a severe headache, which is treatable." "My blood pressure may increase if I lie down too soon after the injection." "I can expect immediate anesthesia that can be reversed very easily."
"The anesthetic may cause a severe headache, which is treatable."
A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? The fetal scalp electrode is a small device that looks like a corkscrew. It's applied quickly after the baby's scalp is carefully palpated. Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Inform the client that the fetal scalp electrode helps monitor fetal heart rate and assists with shortening the first stage of labor.
Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission.
A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine inversion. atony. involution. discomfort.
atony.
A primigravid client in active labor, who has had no anesthesia, has managed contractions using slow chest breathing. The client's cervix is 7 cm dilated, and the client is starting to feel considerable discomfort during contractions. Which breathing technique should the nurse instruct the client to try next? rapid, shallow chest breathing deep chest breathing rapid pant-blow breathing slow abdominal breathing
rapid, shallow chest breathing
A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section? physician admitting nurse the nurse assigned to the client senior staff nurse
physician
A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion? fetal heart rate variability within 5 to 10 beats/minute persistent fetal bradycardia late decelerations variable decelerations and sinusoidal pattern
fetal heart rate variability within 5 to 10 beats/minute
During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem? congenital anomalies pulmonary hypertension meconium aspiration syndrome respiratory distress syndrome
respiratory distress syndrome
A client who gave birth to their last infant by cesarean birth is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have the client undergo "a trial labor." What does the nurse explain to the client that trial of labor means? Labor will be stimulated with exogenous oxytocin until birth. The HCP needs more information to determine the presence of true labor. Labor progress will be evaluated continually to determine appropriate progress for a vaginal birth. Labor will be arrested with tocolytic agents after 2 hours even if no fetal distress is noted.
Labor progress will be evaluated continually to determine appropriate progress for a vaginal birth.
A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next? Continue monitoring per standards of care. 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.
A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern? spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds late decelerations that occur with over 50% of contractions repetitive (at least 3) uncomplicated variable decelerations late decelerations with minimal variability
spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. The client has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, they receive nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor? maternal fatigue fetal malposition small-for-gestational-age fetus effects of analgesic medication
effects of analgesic medication
A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the right occiput posterior position. The nurse should place the client in which position for pain relief? lithotomy right lateral position hands and knees squatting
hands and knees
The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose? assessment of the fetal hematocrit level increase in the strength of the contractions increase in the fetal heart rate and variability assessment of fetal position
increase in the fetal heart rate and variability
A multigravid laboring client has an extensive history of drug abuse disorder. The client's last reported usage was 5 hours ago. They are 2 cm dilated with contractions every 3 minutes of moderate intensity. The health care provider prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states they think they are going to have their baby now. Of the drugs available at the time of the birth, which should the nurse avoid using with this client in this situation? lidocaine 1% naloxone local anesthetic pudendal block
naloxone
A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care? offering support by reviewing the short-pant form of breathing administering opioid analgesia encouraging the mother to receive epidural anesthesia watching for rupture of the membranes
offering support by reviewing the short-pant form of breathing
The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean birth. The client tells the nurse that they have been taking gingko biloba to help manage blood sugar. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication? medication interactions hypertensive crisis oversedation prolonged bleeding
prolonged bleeding
A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? human resource director, so she can arrange vacation time for the staff physician, so he can provide education about HELLP syndrome social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff chaplain, because his educational background includes strategies for handling grief
chaplain, because his educational background includes strategies for handling grief
The nurse is assisting in the birthing room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate childbirth. Which interventions should the nurse perform when caring for the client after this procedure? Select all that apply. check the episiotomy repair site apply ice to the perineum change the dressings every shift administer pain medication, as prescribed explain perineal care to the client when she can focus on the instructions
check the episiotomy repair site apply ice to the perineum administer pain medication, as prescribed explain perineal care to the client when she can focus on the instructions
A primigravid client at about 36 weeks' gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which person must the nurse notify? nursing unit manager so appropriate agencies can be notified head of the hospital's security department chaplain in case the fetus dies in utero health care provider who will attend the birth of the infant
health care provider who will attend the birth of the infant
A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? oxytocin 30 units in 500 mL dextrose 5% in water (D5W) prostaglandin gel 0.5 mg misoprostol 50 mcg dinoprostone 10 mg
oxytocin 30 units in 500 mL dextrose 5% in water (D5W)
Due to a prolonged stage II of labor, the client is being prepared for an assisted vaginal birth. What information related to the mother and neonate's care must the nurse consider? A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps. Using forceps will cause the neonate to develop a cephalohematoma and a vacuum extractor will not. Assisted vaginal births are very commonplace, especially in clients who have received epidurals. Clients having assisted vaginal births are less likely to experience a postpartum hemorrhage.
A vacuum extractor causes less trauma to the neonate and the mother's perineum than forceps.
The health care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the oxytocin induction? Administer a 500-ml bolus of intravenous fluid to prevent hypotension. Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes. Insert an indwelling urinary catheter to determine intake and output accurately. Call the anesthesiologist to begin administration of epidural anesthesia.
Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes.
A nurse has been providing care to a client in labor for the past 9 hours. The partner remains at the bedside while the laboring client is sleeping with the epidural block in situ. Which is the most appropriate nursing action? Encourage the partner to take a break for 1 hour. Instruct the partner to contact another support person take their place because the partner is exhausted. Offer to remain with the client while the partner takes a short break. Suggest that the partner goes home to sleep for a few hours.
Offer to remain with the client while the partner takes a short break.
The nurse is caring for a client who is in the transitional stage of labor. The client's partner is concerned and asks, "What else can I do for my partner? She is so irritable." Which of the following interventions would the nurse suggest? Select all that apply. "Your partner should not be this upset. I will call the doctor immediately." "Encourage your partner to rest in between contractions." "Continue to praise your partner and give her encouragement." "Stay by your partner's side. It is important that she knows you are there to support her." "It is time to have your partner push. I will help you explain what to expect."
"Encourage your partner to rest in between contractions." "Continue to praise your partner and give her encouragement." "Stay by your partner's side. It is important that she knows you are there to support her."
An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician. Honor the mother's request. Knowing the client's cultural background, suggest that the family call a meeting to make the decision. Request that an anesthetist administer the epidural because the client is uncomfortable.
Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug? The cervix will begin to dilate 2 cm per hour Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, with moderate-intensity resting tone between contractions. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, with moderate-intensity resting tone between contractions.
