Intrapartum Period - ML8 (1)

The nurse is teaching a G2P1 client about her upcoming labor. Which response would indicate to the nurse that further teaching is necessary? "Braxton Hicks contractions may stop if I walk or drink water." "I may have blood-tinged mucus when my cervix begins to efface." "I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long." "I should contact my doctor if I experience a sudden gush of vaginal fluid."

"I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long." Although a woman having her second baby (gravida 2) may have a shorter labor than her first labor, she should still contact the healthcare provider when the contractions are every 5 minutes for at least 1 hour. Waiting until the contractions are every 2 minutes is too late. Braxton Hicks contractions do not cause cervical dilation and may stop when the client ambulates or hydrates. As a woman's cervix begins to efface, she may experience a blood-tinged mucus, known as a bloody show.

A client in active labor is planning on epidural anesthesia for labor and birth. After the anesthesiologist has explained the procedure and potential complications, the nurse determines that the client needs further instructions when she makes which statement? "Sometimes the labor process is slower after the epidural anesthesia is administered." "I may not feel the urge to push with this type of anesthesia." "If my bladder gets full, I may need to be catheterized." "I may need to lie flat for 6 hours and drink plenty of fluids after I give birth."

"I may need to lie flat for 6 hours and drink plenty of fluids after I give birth." Lying flat and drinking fluids are interventions for client's experiencing headaches from spinal anesthesia. Such adverse effects do not occur with epidural anesthesia. Anesthesia and analgesia can slow the process of labor. Epidural anesthesia is associated with a decreased urge to void; therefore, catheterization of a full bladder may be necessary. Because the client is anesthetized, the client may not feel the urge to push, so bearing-down efforts during the second stage of labor may be less effective.

After the nurse explains about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed? "My contractions are going to be less painful." "I should try to push with each contraction." "My membranes are likely to have a foul odor." "I'm going to have a higher blood pressure."

"I should try to push with each contraction." The second stage of labor begins with complete cervical dilation and ends with birth. During this time, the client is encouraged to push with each contraction. Throughout labor, the client's blood pressure should remain within normal limits. The membranes often rupture in the second stage of labor, but they also may rupture earlier—in some instances, even before labor begins. However, the fluid should not have a foul odor, which is indicative of an infectious process. Contractions can be strong and painful in the first stage of labor as well as the second stage.

The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict? "Please try to understand that the physician is a professional and will be escorted by a female nurse." "Clients cannot always be guaranteed there will be a female physician on call." "I will make every effort to work with your cultural beliefs." "Your attitude toward the male physician could put the baby at risk."

"I will make every effort to work with your cultural beliefs." The nurse knows they must make every effort to respect and work within the cultural limitations in each client situation. Telling the family they are compromising the health of their baby may be inaccurate information, and the language used by healthcare providers can have a powerful effect on clients and families. Educating the family surrounding the physician's on-call schedule does not facilitate open communication or culturally sensitive care. Nurses should refrain from encouraging convincing or changing health behaviors and needs of clients and avoid assuming that a person and family will conform to a particular form or pattern of care.

A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the teaching when the client makes which statement? "My baby's heart rate is slow because of my infection." "If left untreated, my baby might be born with an infection." "Women who are overweight are more likely to get this infection." "My infection is the cause of my hypertonic labor pattern."

"If left untreated, my baby might be born with an infection." Chorioamnionitis is a serious intrapartum infection that may result in fetal tachycardia and a hypotonic labor pattern. If left untreated, infected amniotic fluid in the fetal lungs may result in an infection, such as pneumonia, during the neonatal period. Typically chorioamnionitis results in fetal tachycardia, not bradycardia. Chorioamnionitis usually results in a maternal fever and tachycardia. It is not associated with hypertonic labor patterns. No relationship is known between being overweight and development of chorioamnionitis.

A client hospitalized for preterm labor tells the nurse her mother-in-law blames her for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse? "Let's talk about how preterm labor occurs to help you understand what causes it." "Did you think that you did anything you shouldn't have?" "It is natural to blame one another when things become difficult." "Your mother-in-law was wrong. You didn't do anything to cause this."

"Let's talk about how preterm labor occurs to help you understand what causes it." The nurse needs to explore the client's feelings to assist her in understanding what happened and to disperse the blame she is feeling. The other responses do not explore feelings experienced by the client and may stop the dialogue with the nurse from continuing.

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. "Encourage your partner to rest in between contractions." "Continue to praise your partner and give her encouragement." "Your partner should not be this upset. I will call the doctor immediately." "It is time to have your partner push. I will help you explain what to expect." "Stay by your partner's side. It is important that she knows you are there to support her."

"Stay by your partner's side. It is important that she knows you are there to support her." "Continue to praise your partner and give her encouragement." "Encourage your partner to rest in between contractions." Transition is the time during labor where the client is 8-10 cm dilated. This is too early for the client to push and it is not uncommon for the client to be very irritable. Encouragement to sleep during contractions with praise and encouragement are appropriate interventions. During this period, the client is very anxious and may have a fear of being left alone. Keeping a presence at the client's bedside is an important intervention.

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? "The baby will be given a drug to dilate the bronchi." "The baby will be given oxygen by a mask." "A tube will be placed in the baby's nose." "Suctioning will be needed if the baby is floppy."

"Suctioning will be needed if the baby is floppy." Suctioning is only required if a baby is floppy or presents with poor respiratory effort. Meconium aspiration blocks the air flow to the alveoli, leading to potentially life-threatening respiratory complications.Routinely, the neonate is not intubated unless respiratory complications develop.Oxygen is usually not administered unless complications arise.Bronchodilators typically are not used unless meconium aspiration occurs along with respiratory distress.

A client had a cesarean section with her first pregnancy and is hoping to have a vaginal birth with this pregnancy. She begins to cry at her 38-week visit when she realizes that her baby is a breech presentation. She says, "I just know it's going to be horrible again. I won't be able to breastfeed my baby. It will be painful." What response from the nurse is appropriate? "Don't worry. We will be here to help you through this." "A cesarean section is always done for breech presentation." "It is safer to have a cesarean section than a vaginal birth after cesarean." "Tell me about your previous baby's birth."

"Tell me about your previous baby's birth." The client appears to be afraid of having another cesarean section (C-section). The nurse needs to allow the client to express her fears and also needs to listen to what problems she experienced last time so the nurse is able to address each one. This kind of open-ended question facilitates effective and therapeutic communication. Although a C-section may be performed for a breech birth, at times a vaginal breach birth may be attempted, depending on family desire, potential benefits, and maternal and fetal risk factors. There are higher rates of morbidity and mortality with a C-section compared to a vaginal birth after cesarean (VBAC).

The nurse is explaining to a client why she can have only fluids while in labor. Which client statement indicates that the teaching has been effective? "The digestive process is normally slow during labor." "Most clients don't get hungry during labor." "Eating solid foods during labor is unnecessary." "Intravenous fluids will be started if I get hungry."

"The digestive process is normally slow during labor." Recommendations for food and fluid intake during labor vary widely in the literature and in clinical practice. Because gastric emptying is slower in pregnancy and labor and the potential for nausea and vomiting (common late in the first stage of labor) poses a risk for aspiration of stomach contents, clients are often limited to clear fluids or ice chips.Many institutions have a policy of administering intravenous fluids to prevent dehydration or to have an intravenous line in place in case the client needs medications or blood replacement. Intravenous fluids are not used to quell hunger.Because gastric emptying is delayed during pregnancy and labor, the client is at risk for aspiration of stomach contents. Recommendations for fluid intake during labor are based on this and not the client's degree of hunger.Eating solid foods can lead to vomiting and possible aspiration.

The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response? "It is too early to tell, we will need to repeat the test in 2 weeks." "The fetal heart rate went up twice during the test, so your fetus is doing well." "The fetal heart rate dropped during the contractions, so we may need to induce you." "I'm sorry, your provider will have to inform you of the results of the test."

"The fetal heart rate went up twice during the test, so your fetus is doing well." During a nonstress test, an electronic fetal monitor provides a tracing of the fetal heart rate (FHR). Normally, the FHR accelerates with movement, indicating that the fetus has an intact autonomic nervous system that is not affected by uterine hypoxia. A reactive (normal) nonstress test with two accelerations going up 15 beats per minute and lasting 15 seconds in 20 minutes is a sign of fetal well-being. A nonstress test may be performed anytime after 32 weeks' gestation. Contractions are stimulated for a contraction stress test (CST); a positive CST is indicative of a fetus that may not handle the stress of labor well.

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? "No, only certified registered nurses can perform this skill." "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first." "Yes, but only after you read about the procedure in the regional policy and procedure manual." "Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

"Yes, but I will demonstrate it once and then supervise you while you perform the procedure." This method of instruction facilitates student learning by demonstration. The nurse is accountable for delegating nursing interventions to student learners. Experiential learning is an effective method of developing psychomotor tasks and critical thinking skills. EFM is not a certifiable skill specific to registered nursing practice and does not require that it be practiced in an acute care setting prior to practicing it in a community setting. It is critical that the nurse first demonstrates and then supervises the skill to ensure student learning and client safety.

The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She is too upset by what is happening to make this decision." What should the nurse do? Ask the client to sign the consent form. Ask the HCP to witness the consent form. Have the client and her husband both sign the consent form. Ask the client if this is acceptable to her.

Ask the client to sign the consent form. Preparation for cesarean birth is similar to preparation for any abdominal surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain designated people can do so legally. The husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery may be performed without a written consent if it is done to save the life of the mother or the child, or both.

A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time? Increase the IV oxytocin to 125 mL/hr for hydration. Ask the client what fluids she prefers to drink. Offer the client hot beverages. Encourage client to drink the ice and water.

Ask the client what fluids she prefers to drink. Although it is common for Asian childbearing women to drink only hot beverages (birth philosophy related to yin and yang), it would be appropriate first to find out from the client what she wants to drink and determine her likes and dislikes. There is a reason she has chosen not to drink the cold beverages, so it is best to ask her what it is she does want. Increasing the oxytocin would likely increase her uterine contractions and is not appropriate practice for meeting the needs of hydration.

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first? Assess the fetal heart rate (FHR) for 1 full minute. Assess the client's temperature and pulse. Monitor the client's contraction pattern. Document the color of the amniotic fluid.

Assess the fetal heart rate (FHR) for 1 full minute. After an amniotomy, the nurse should plan to first assess the FHR for 1 full minute. One of the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm or less should be promptly reported to the HCP. A cord prolapse requires prompt birth by cesarean section. The client's contraction pattern should be monitored once labor has been established. The client's temperature, pulse, and respirations should be assessed every 2 to 4 hours after rupture of the membranes to detect an infection. The nurse should document the color, quantity, and odor of the amniotic fluid, but this can be done after the FHR is assessed and a normal pattern is present.

While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, "I think my water just broke." What should the nurse do first? Turn the client to the right side. Assess the color, amount, and odor of the fluid. Assess the fetal heart rate pattern. Check the client's cervical dilation.

Assess the fetal heart rate pattern. After spontaneous rupture of the amniotic fluid, the gushing fluid may carry the umbilical cord out of the birth canal. Sudden deceleration of the fetal heart rate commonly signifies cord compression and/or prolapse of the cord, which would require immediate birth. This client is particularly at risk because the fetus is preterm and the fetal head may not be engaged. Turning the client to the right side is not a priority action. However, changing the client's position would be appropriate if variable decelerations are present. The nurse should assess the color, amount, and odor of the fluid, but this can be done once the fetal heart rate is assessed and no problems are detected. Cervical dilation should be checked but only after the fetal heart rate pattern is assessed.

A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first? Turn the client to a knee-to-chest position. Assess the fetal heart rate. Increase the rate of the oxytocin infusion. Assess cervical dilation and effacement.

Assess the fetal heart rate. Assessing the fetal heart rate is always a priority after spontaneous rupture of membranes has occurred. Meconium-stained fluid is also a common sign of fetal distress related to an inadequate transfer of oxygen to the fetus. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary. In addition, all clients are monitored continuously after rupture of membranes for fetal distress caused by cord prolapse. If there are increasing signs of fetal distress (e.g., late decelerations), the health care provider (HCP) should be notified immediately. A cesarean birth may be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal distress. Turning the client to the left side, rather than a knee-chest position, improves placental perfusion. The HCP may wish to determine the extent of cervical dilation to make a decision about whether a cesarean birth is warranted, but continuous fetal heart rate monitoring is essential to determine fetal status.

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission? Ensure that the client will have a support person in labor. Assess the client's coping skills in labor. Review the client's obstetrical history. Assess the imminence of birth.

Assess the imminence of birth. This is the client's fifth baby, and she has been in labor for 3 hours. Given that multipara clients experience the stages of labor at a significantly faster rate than nullipara clients, it is critical that the nurse assess for the imminence of birth. After this has been established, the nurse will know how much time is available to review the obstetrical history, assess the client's coping skills, and ensure the presence of a support person for the labor and birth.

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 dominant and there is no likelihood of the baby having cystic fibrosis. Autosomal dominant and there is a 50 per cent chance of the baby having the disease. X-linked recessive and the disease will only occur if the baby is a boy. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.

Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemophilia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typically manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan's syndrome, and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene.

The nurse has just received report on a labor client: a G3, T1, P0, Ab1, L1 who is 80% effaced, 3 cm dilated, 0 station. The nurse anticipates the plan of care for the shift will include address what factors? Select all that apply. Stage 2 should take 30 minutes or less. Contractions will remain irregular until transition. Birth should occur before the change of shift in 12 hours. This client will withdraw into herself during transition. Transition will be shorter for this multiparous client.

Birth should occur before the change of shift in 12 hours. This client will withdraw into herself during transition. Transition will be shorter for this multiparous client. Stage 2 should take 30 minutes or less. A multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 minutes or less and many multiparous clients go immediately from 10-cm dilation to birth. Contractions become regular and increase in frequency, intensity, and duration as labor progresses for both primiparous and multiparous clients. Transition will be shorter for a multiparous client than it will for a primiparous client, as the entire labor process takes less time for someone who has had a baby before. This client will withdraw into herself during transition, and this is a common characteristic for those in the transition phase.

The nurse caring for a multigravida in active labor observes a variable fetal heart rate deceleration pattern. What should the nurse do first? Change the client's position. Administer oxygen by mask at 4 L. Document the tracing in the client's record. Contact the client's primary care provider.

Change the client's position. A variable deceleration pattern of the fetal heart rate is usually due to cord compression. This may be a result of the cord around the presenting part, a short cord, or the maternal position. Treatment involves changing the maternal position. If this does not resolve the variable heart rate pattern, the primary care provider or nurse midwife should be notified.Oxygen may be needed at a rate of 8 to 10 L.If changing the position does not resolve the problem, the primary care provider should be notified.Documenting the problem does not resolve the problem of cord compression.

External monitoring of contractions and fetal heart rate of a multigravida in labor reveals a variable deceleration pattern on the fetal heart rate. What should the nurse do first? Administer oxygen at 2 L by mask. Notify the anesthesiologist. Change the client's position. Prepare the client for a cesarean birth.

Change the client's position. Variable decelerations, common after membranes rupture, usually indicate cord compression. Repositioning the client often helps to correct this fetal heart rate pattern. If repositioning is not successful, the clinician may choose to perform amnioinfusion of sterile saline solution into the uterus through a sterile catheter to help take the pressure off the cord.The nurse may wish to alert the obstetrician or nurse midwife, but the anesthesiologist is responsible for anesthesia, not for the fetus.Administering oxygen at 2 L is not helpful because pressure on the cord must be relieved first.Changing the client's position and administering oxygen often resolve the cord compression. There is no need to prepare the client for a cesarean birth at this time. A cesarean birth would be indicated for prolonged fetal distress.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes? Assess the client's blood pressure. Check the fetal heart rate. Position the client on her left side. Prepare the client for a cesarean birth.

Check the fetal heart rate. Immediately after a spontaneous rupture of the membranes, the nurse should listen to the fetal heart rate to detect bradycardia. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. Fetal heart rate should be monitored because it will indicate if cord prolapse or cord compression has occurred. The color, amount, and odor of the amniotic fluid should be noted.Although the optimal position for the client is side lying, this is not a priority at this time.The client is not having a precipitous birth with the fetal head at ?1 station. Therefore, preparing the client for a cesarean birth is unnecessary.Although maternal blood pressure should be monitored throughout labor, this is not a priority at this time.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? Tell the partner that to leave because the partner is intimidating the client. Question the woman in front of her partner. Contact hospital security to escort the partner from the hospital. Collaborate with the physician to make a referral to social services.

Collaborate with the physician to make a referral to social services. Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her partner does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first? Complete a vaginal examination. Document the client's relief due to pain medication. Prepare for birth. Have naloxone hydrochloride available in the birthing room.

Complete a vaginal examination. The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by completing a vaginal exam to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining naloxone. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? Contractions will be stronger and shorter and will peak more slowly. Contractions will be stronger and more uncomfortable and will peak more abruptly. Contractions will be stronger, shorter, and less uncomfortable. Contractions will be weaker, longer, and more effective.

Contractions will be stronger and more uncomfortable and will peak more abruptly. Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions.

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? Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg. The cervix will begin to dilate 2 cm/h. Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, 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 occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. The goal of oxytocin administration in labor augmentation is to establish an adequate contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contractions occurring every 2 to 3 minutes, lasting 40 to 60 seconds, of moderate intensity with a palpable resting tone between contractions. Other contraction patterns will cause the cervix to dilate too quickly or too slowly. Cervical changes in softening, effacement, and moving to an anterior position are associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2 cm/h is too rapid for the induction/augmentation process.

A nurse is caring for a woman G1 P0 at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation; FHR baseline is 135 bpm and decreases to 125 bpm shortly after 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? Document findings on the client's chart, and continue to monitor labor progress. Notify the health care provider (HCP) immediately, and prepare for emergency caesarean birth. Perform vaginal exam to rule out umbilical cord prolapse. Position the client on her left side, and administer O2 via face mask.

Document findings on the client's chart, and continue to monitor labor progress. The nurse would document these findings as "early" decelerations, which begin before the peak of the contraction. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered a normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or O2 as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean birth.

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? Place the woman supine with her legs raised. Ensure adequate hydration before the anesthetic is administered. Administer oxygen using a mask. Administer ephedrine to raise her blood pressure.

Ensure adequate hydration before the anesthetic is administered. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.

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? 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. Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. 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.

Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Explaining what the fetal scalp electrode is, how it's applied, and that bedrest is required after application provides correct information about fetal scalp electrode application; however, these statements don't address the client's clinical situation, which prevents fetal scalp electrode application. The fetal scalp electrode helps monitor fetal heart rate, but it doesn't shorten labor.

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 should have the client who is 5 cm dilated and experiencing the urge to push to blow out her breath to keep from pushing. Encouraging the client to push with the next contraction would cause traumatic swelling of the cervix caused by the attempt to force the fetus through an incompletely dilated cervix. Pain medication and/or a cesarean section is not indicated by the client's urge to push.

The nurse is reviewing a client's prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth? Urinary tract infection at 16 weeks gestational age Gravida 4, Para 3 History of postpartum hemorrhage (PPH) Amniocentesis performed at 14 weeks gestational age

History of postpartum hemorrhage (PPH) Women who have a history of PPH are at higher risk for a PPH in subsequent pregnancies. This is a significant factor for the nurse to know in planning and being prepared for the birth of the baby because this is the client's fourth labor and birth. Urinary tract infections may occur during pregnancy as the enlarging uterus puts pressure on the ureters, resulting in urinary stasis. However, there is not a significant impact on labor and birth. Following amniocentesis, the client may experience cramping and feelings of increased pressure. The associated complications with amniocentesis are proximal (infection, fetal injury, bleeding) but do not pose a long-term consequence in relation to the labor process.

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? Exert downward pressure as if having a bowel movement. Be in a semi-Fowler's position or a position of comfort Flex the thighs onto the abdomen before bearing down. Hold the breath throughout the length of the contraction.

Hold the breath throughout the length of the contraction. The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing.Semi-Fowler's position enhances the effectiveness of the abdominal muscle efforts during pushing, but the client can assume a squatting or side-lying position if desired.The client should flex her thighs onto her abdomen before bearing down to decrease the length of the vagina and increase the pelvic diameter.The client should exert downward pressure as if she were having a bowel movement while pushing.

The nurse is assisting with the birth of a fetus in a frank breech presentation. Which graphic illustrates that position?

In a frank breech presentation, the buttocks are the presenting part, with the hips flexed and the knees remaining straight. In a complete breech (option 1), the knees and hips are flexed. In a footling breech (option 2), neither the hips nor lower legs are flexed, and one or both feet may present. In an incomplete breech (option 4), one or both hips remain extended, and one or both feet or knees lie below the breech.

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse? Explain to the client that she should lie down and restrict her activity. Advise the client to wait and see if her symptoms progress. Instruct the client to go to an emergency room for an urgent assessment. Instruct the client to call her physician.

Instruct the client to go to an emergency room for an urgent assessment. The client is experiencing bright red bleeding and mucus that could be loss of her mucus plug and is often a sign of impending labor. The client needs to be seen immediately at an urgent-care medical facility. All of the other actions are not urgent enough.

A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her partner, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time? Teach the client progressive muscle relaxation. Teach the client and her partner about pain transmission. Instruct the partner on touch, massage, and breathing patterns. Use hypnosis on the client and her partner.

Instruct the partner on touch, massage, and breathing patterns. If the unprepared client has a support person, the nurse should focus on that person's supporting role, demonstrating touch, massage, and simple breathing patterns. Teaching about muscle relaxation, hypnosis, or pain transmission is inappropriate at this time because this information may make the client and her partner more anxious.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately? Place a pillow under the left buttock. Insert a padded tongue blade into the mouth. Pad the side rails. Maintain a patent airway.

Maintain a patent airway. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure.Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure.Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.

During the fourth stage of labor, a nurse notes that the client's fundus is boggy and located above the umbilicus. What is the nurse's priority intervention? Massage the client's fundus. Assess the amount of lochia on the client's pad. Notify the healthcare provider. Insert a straight catheter to empty the bladder.

Massage the client's fundus. A boggy (soft and poorly contracted) fundus signals uterine atony. To correct this condition, the nurse should massage the fundus until it becomes firm and clots are expressed. Allowing a boggy fundus to persist would place the client at high risk for postpartum hemorrhage. The fundal massage should begin immediately, after which the nurse can check the pad. The nurse should notify the healthcare provider only if the client's fundus doesn't respond to massage. Although an empty bladder can facilitate uterine contraction, the priority is not the insertion of a catheter.

The nurse assesses the postpartum client and notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What is the nurse's priority intervention? Call the healthcare provider. Check the blood pressure. Massage the fundus. Insert an indwelling urinary catheter.

Massage the fundus. Uterine atony can contribute to postpartum hemorrhage, which results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. The priority measure to correct postpartum hemorrhage is to massage the fundus. Emptying the bladder via indwelling catheter and checking vital signs are not priorities. Massaging the fundus will increase uterine tone and decrease vaginal bleeding. The healthcare provider will have to be called, but the nurse must first intervene. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus.

A nurse is administering oxytocin to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's plan of care? Insert an indwelling catheter. Monitor of intake and output. Maintain bed rest. Restrict oral intake.

Monitor of intake and output. Oxytocin has an antidiuretic effect; prolonged I.V. infusion may lead to severe fluid retention, resulting in seizures, coma, and even death. Therefore, the nurse should monitor intake and output closely. It isn't necessary to insert a catheter. Clients in labor have do not oral fluid restrictions. There is no need for the client to maintain complete bed rest.

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? 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. Encourage the partner to take a break for 1 hour. 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. It is possible that the partner is reluctant to leave the client alone during this time. It is appropriate, if possible, for the nurse to offer to stay with the client while the partner goes for a break. The partner will be able to take a break and know that the client is not alone at the time. The nurse should not direct or instruct the partner to go home or to have another support person come in. It is important that the nurse is respectful of client and family desires.

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives 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? small-for-gestational-age fetus fetal malposition maternal fatigue effects of analgesic medication

effects of analgesic medication Decreased variability may be seen in various conditions. However, it is most commonly caused by analgesic administration. Other factors that can cause decreased variability include anesthesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage, and arrhythmias. Maternal fatigue, fetal malposition, and small-for-gestational-age fetus are not commonly associated with decreased variability.

A client in labor asks the nurse about Reiki, an alternative therapy that she's heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of vigorous massage. energy from a light source. energy from light touch. mind-body control.

energy from light touch. Reiki is based on the principle that energy from hands being placed lightly on or at a distance from the body can be used to heal. Reiki doesn't involve vigorous massage, energy from a light source, or mind-body control.

A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? Perform a straight catheterization for protein analysis. Complete an initial assessment on a client. Assess a laboring client for a change in labor pattern. Increase the oxytocin rate on a laboring client.

Perform a straight catheterization for protein analysis. The straight catheterization is within the scope of practice of a licensed practical nurse. An initial or continuing assessment is the responsibility of the registered nurse. Assessment must be complete before increasing the IV rate of oxytocin. The assessment and the increase in oxytocin rate are responsibilities for the nurse.

The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" Her last vaginal exam 1 hour ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client? Perform a vaginal examination to determine if the client is fully dilated. Ask the client for suggestions to make her more comfortable. Help the client through contractions until a narcotic can be given. Palpate the bladder to see if it has become distended.

Perform a vaginal examination to determine if the client is fully dilated. Transition is the most difficult period of the labor process, and often when clients are tired, pain becomes more intensified. Clients during this stage verbalize anger and are outspoken and difficult to comfort. The most logical next step would be to determine if the client has completed transition and is ready to begin pushing. Performing a vaginal exam would provide this answer. The use of narcotic medications is discouraged at this stage as they can lead to respiratory depression in the neonate. Palpating the bladder is an important intervention but not the highest priority as it was done less than an hour ago. Since the nurse has correctly completed the most logical steps, asking for the client's input would certainly be in order but not the highest priority intervention.

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first? Begin oxygen by face mask at 8 to 10 L/min. Place the cord back into the vagina to keep it moist. Place gentle pressure upward on the fetal head. Turn the client on her left side.

Place gentle pressure upward on the fetal head. The nurse should place a hand on the fetal head and provide gentle upward pressure to relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother, but until the compression on the cord is relieved, the increased oxygen will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be position changes to increase perfusion to the infant by relieving cord compression.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? Ask the client to begin pushing. Place the client in a Trendelenburg position. Administer oxytocin intravenously. Cover the cord with sterile towels.

Place the client in a Trendelenburg position. The first step in managing a cord prolapse is to relieve pressure on the cord. Immediate measures include lowering the client's head by using the Trendelenburg position or knee-to-chest position so that the fetal presenting part will move away from the pelvis and moving the fetal presenting part off the cord by applying pressure through the vagina with a sterile gloved hand. An immediate cesarean birth is usually performed.Oxytocin would not be given because the drug stimulates uterine contractions, putting further pressure on the cord as the contractions attempt to expel the fetus.Pushing results in further cord compression and decreased fetal heart rate.With cord prolapse, an immediate cesarean birth is indicated. There is no need to cover the cord to avoid damage or tearing.

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? Place the mother in a knee-to-chest position. Restore circulation by stimulating the cord with a sterile glove. Attempt an external cephalic rotation. Palpate the cord for pulsations before notifying the physician.

Place the mother in a knee-to-chest position. The knee-to-chest position helps lift the presenting part off the umbilical cord. If, upon vaginal examination, a loop of cord is discovered, the nurse should keep gloved fingers in the vagina and push on the fetal presenting part to keep the part off the cord, thus relieving cord compression until the physician or midwife arrives. It is inappropriate to attempt an external cephalic rotation. Cord pulsations may not be felt; therefore, oxygen should be administered and electronic fetal monitoring should be put in place immediately to monitor the fetal heart rate and well being.

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. A client who is fully dilated is about to begin pushing. Appropriate actions for this time include assessing vital signs every 15 minutes, positioning for effective pushing, and preparing for delivery. Oxytocin is administered to induce labor or to help the uterus contract after birth; it would be inappropriate to administer to a client entering the second stage of labor. It is inappropriate to insert an epidural when the client is ready to start pushing. Status of membranes would have been determined during the sterile vaginal exam.

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? Prepare the client for an emergency cesarean birth. Perform a sterile vaginal exam (SVE). Insert an intrauterine pressure catheter. Reposition the client.

Prepare the client for an emergency cesarean birth. The priority action is to prepare for an emergency cesarean birth as a sharp, tearing pain along with absence of contractions on the EFM indicate a uterine rupture, which is an extreme emergency. Performing an SVE, inserting an intrauterine pressure catheter, and repositioning the client do not address the emergency situation and are not the priority action.

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding? contractions 3 minutes apart and lasting 40 seconds an episode of nausea after administration of an epidural anesthetic evidence of spontaneous rupture of the membranes sleeping after administration of IV nalbuphine

evidence of spontaneous rupture of the membranes The nurse expects the UAP assigned to several clients in labor to notify the nurse if the UAP observes that one of the clients has evidence of spontaneous rupture of the membranes. When the membranes rupture spontaneously, there is danger of a prolapsed cord, a medical emergency requiring a cesarean birth.Nausea may occur after administration of an epidural anesthetic, but this is not a priority or emergency.Having contractions that are 3 minutes apart and last for 40 seconds is normal during active labor.Because nalbuphine is an analgesic, it is normal for a client to fall asleep after intravenous administration of this drug.

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia? excessive fetal activity and fetal tachycardia abnormally long uterine contractions abnormally strong uterine contractions excessively frequent contractions, with rapid fetal movement

excessive fetal activity and fetal tachycardia Fetal tachycardia and excessive fetal activity are the first signs of fetal hypoxia. The duration of uterine contractions is within normal limits. Uterine intensity can be mild to strong yet still within normal limits. The frequency of contractions is within normal limits for the active phase of labor.

For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with moderate variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for which problem? meconium-stained fluid. chills and fever. exhaustion. fluid overload.

exhaustion. The normal length of the latent stage of labor in a primigravid client is 6 hours. If the client is having prolonged labor, the nurse should monitor the client for signs of exhaustion as well as dehydration. Hypotonic contractions, which are painful but ineffective, may be occurring. Oxytocin augmentation may be necessary. Chills and fever are manifestations of an infection and are not associated with a prolonged latent phase of labor. Fluid overload can occur from rapid infusion of intravenous fluids administered if the client is experiencing hemorrhage or shock. It is not associated with prolonged latent phase. The client's membranes are intact, so it would be difficult to assess meconium staining of the fluid. Meconium-stained fluid is associated with fetal distress, and this fetus appears to be in a healthy state, as evidenced by a fetal heart rate within normal range and good variability.

A client whose cervix is 10 cm dilated begins to push. The nurse notes early decelerations of the fetal heart rate. The nurse should interpret this finding as being caused by which factor? fetal bradycardia cord compression fetal head compression inadequate uteroplacental perfusion

fetal head compression Early decelerations are usually due to pressure on the fetal head as the fetus progresses through the birth canal. These decelerations mirror the contraction pattern and are usually benign, unless the pattern occurs in early labor. If this pattern is demonstrated in early labor, it may indicate cephalopelvic disproportion.Variable decelerations are associated with cord compression.Fetal bradycardia may occur as a result of analgesia and can occur at any time.Inadequate placental perfusion is associated with late fetal heart rate decelerations.

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? Avoid the use of analgesics for the labor pain. Remain in a side-lying position with the head elevated. Breathe slowly after each contraction. Request local anesthesia for vaginal birth.

Remain in a side-lying position with the head elevated. The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor.

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? Ask the client if she agrees with her partner's desire to stay in the waiting room. Inform the client and her partner that only fathers can stay in the birthing room. 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.

Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born. This statement respects the decision of the family and facilitates open communication among the nurse, the client, and the client's partner during labor and birth.

A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse should contact the health care provider (HCP) for clarification in what circumstance? The client's membranes have ruptured. The client's pregnancy is multifetal. The client is exhibiting hypotonic labor patterns. The client has been diagnosed with type 2 diabetes.

The client's membranes have ruptured. Some HCPs do not allow clients with ruptured membranes to use a hot tub or jet hydrotherapy tub during labor for fear of infections. The nurse should check with the HCP before continuing. Jet hydrotherapy is not contraindicated for clients with multifetal gestation, diabetes mellitus, or hypotonic labor patterns.

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered? The cord lengthens outside the vagina. The uterus cannot be palpated. There is decreased vaginal bleeding. The uterus changes to discoid shape.

The cord lengthens outside the vagina. The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes firmer and changes in shape from discoid to globular. This process takes about 5 minutes. If the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage.

The nurse is explaining to a primagravida in labor that her 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 her baby is positioned?

This figure shows the client's baby in a breech presentation with the baby facing the pelvis on the left, the sacrum as the presenting part, and the presenting part (sacrum) is posterior in the pelvis. Figure 2 shows a vertex presentation with the baby in a left, occiput, anterior position (LOA). Figure 3 shows a vertex presentation, left, occiput, posterior (LOP). Figure 4 shows a face position with the baby in a left, mentum, transverse position (LMT).

A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), what should the nurse do? Perform a vaginal examination. Catheterize the client. Turn the client to her side. Decrease the IV fluid rate.

Turn the client to her side. The nurse should turn the client to the side to reduce pressure on the abdominal aorta. The IV fluid rate would be increased, not decreased. There is no information indicating the client has a full bladder or requires a vaginal examination.

The primary health care provider prescribes whole blood replacement for a multigravid client with abruptio placentae. What should the nurse do first before administering the intravenous blood product? Ask the client if she has ever had any allergies. Check the vital signs before transfusing over 5 to 6 hours. Validate client information and the blood product with another nurse. Administer 100 ml of 5% dextrose solution intravenously.

Validate client information and the blood product with another nurse. When administering blood replacement therapy, extreme caution is needed. Before administering any blood product, the nurse should validate the client information and the blood product with another nurse to prevent administration of the wrong blood transfusion. Although baseline vital signs are necessary, she should initiate the infusion of blood slowly for the first 10 to 15 minutes. Then, if there is no evidence of a reaction, she should adjust the rate of infusion to ensure that the blood product is infused over 2 to 4 hours. The nurse can ask the client if she has ever had a reaction to a blood product, but a general question about allergies may not elicit the most complete response about any reactions to blood product administration. Blood transfusions are typically given with intravenous normal saline solution, not dextrose solutions.

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 discomfort. involution. atony. inversion.

atony. A large fetus, extended labor, stimulation with oxytocin, and traumatic birth commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow birth 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 childbirth.

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? beginning of one contraction to the beginning of the next contraction acme of one contraction to the beginning of the next contraction beginning of one contraction to the end of the next contraction end of one contraction to the end of the next contraction

beginning of one contraction to the beginning of the next contraction To assess the frequency of the client's contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme identifies the peak of a contraction.

What should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? contraction pattern blood pressure cognitive function level of consciousness

blood pressure Administration of an epidural anesthetic can result in a hypotensive effect on maternal blood pressure. Therefore, the priority assessment is the mother's blood pressure. Ephedrine or wedging the client to a position to keep pressure off the vena cava, such as on the left side, can be used to elevate maternal blood pressure should it drop too low. Epidural anesthesia has no effect on the level of consciousness or the client's cognitive function. Although the client's contraction pattern may decrease in frequency after administration of the anesthesia, the priority assessment is the client's blood pressure. After blood pressure is maintained, contractions can be assessed.

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? blood pressure of 146/90 mm Hg treatment for syphilis at 15 weeks' gestation maternal age of 32 years total weight gain of 30 lb (13.6 kg)

blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can 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 (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus.

A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color? blue yellow red white

blue If the client's membranes have ruptured, the nitrazine paper will turn blue, an alkaline reaction. False positives may occur when the nitrazine paper is exposed to blood or semen. The definitive test for rupture of membranes is fern testing, where amniotic fluid is allowed to dry on a slide and then viewed under a microscope. Dried amniotic fluid will form a fern pattern. No other fluid forms this type of pattern.

The nurse has administered promethazine intravenously to a client in active labor. The drug has had the desired effect when the nurse notes which finding? increased contraction strength increased fetal heart rate decreased nausea and vomiting increased blood pressure in the client

decreased nausea and vomiting Promethazine is a tranquilizer that also serves as an antiemetic. It is a muscle relaxant that potentiates narcotics and barbiturates.The fetal heart rate and beat-to-beat variability usually decrease after analgesia is administered.Promethazine does not increase the strength of contractions.Tranquilizers used in labor can decrease the client's blood pressure.

The end of the third stage of labor is marked by what event? delivery of the placenta the birth of the neonate complete dilation transfer of the client to the postpartum bed

delivery of the placenta The third stage of labor is marked by the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 2 hours after birth.

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? social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff human resource director, so she can arrange vacation time for the staff physician, so he can provide education about HELLP syndrome chaplain, because his educational background includes strategies for handling grief

chaplain, because his educational background includes strategies for handling grief The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

The nurse would question the prescription for a fetal scalp electrode on which client? client with late decelerations client with a prolonged second stage of labor client with significant meconium stained fluid client with an HIV infection

client with an HIV infection Placement of a fetal scalp electrode should be avoided when a client has HIV because it increases the risk of transmission to the fetus. The use of a fetal scalp electrode is indicated when precise tracing are needed to monitor changes associated with fetal hypoxia and satisfactory tracing cannot be obtained with external methods.The presence of decelerations, meconium stained fluid, and prolonged second stage of labor may all be indications for placing a fetal scalp electrode.

The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action? open glottis pushing closed glottis pushing "rest and descent" squatting while pushing

closed glottis pushing Closed glottis pushing, or when a woman is told to hold her breath when she pushes typically while the nurse typically counts to 10, creates the Valsalva maneuver and is associated with decreased perfusion. Open glottis pushing, on the other hand, encourages women to listen to their own body cues for when to breathe and when to bear down. "Rest and descent" and squatting have positive influences on the second stage of labor and birth.

A client is attempting to give birth vaginally despite the fact that her previous child was born by cesarean birth. Her contractions are 2 to 3 minutes apart, lasting from 5 to 100 seconds. Suddenly, the client complains of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes which complication has occurred? prolapsed cord complete uterine rupture abruptio placentae partial placenta previa

complete uterine rupture In complete uterine rupture, the client feels a sharp pain in the lower abdomen and contractions stop. Fetal heart rate also stops within a few minutes. In abruptio placentae, uterine instability would continue to be indicated by the fetal heart monitor tracing. With cord prolapse, contractions would continue and the client wouldn't experience pain from the prolapse itself. Although vaginal bleeding occurs with partial placenta previa, the client has no pain outside of the expected pain of contractions.

The nurse assesses the perineal changes of a woman in the second stage of labor. The figure below represents which perineal change? circular shape crowning oval opening anterior-posterior slit

crowning Crowning occurs when the fetal head is visible. Anterior-posterior slit occurs as the perineum flattens and is followed by an oval opening. As labor progresses, the perineum takes on a circular shape, followed by crowning.

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? level of consciousness maternal pulse fetal heart rate level of anesthesia

fetal heart rate The anesthetic used for the epidural block may cause relaxation of maternal blood vessels, leading to lower maternal blood pressure. The decrease in maternal blood pressure causes oxygenated blood to move more slowly to the fetus, commonly leading to a lower fetal heart rate and hypoxia. A major complication is a decreased fetal heart rate. Thus, assessment of fetal heart rate is most important. While measuring maternal pulse is important, this vital sign does not tell the nurse as much about fetal perfusion as the fetal heart rate or maternal blood pressure. Epidural anesthesia has no effect on the status of the membranes or the color of the amniotic fluid. The membranes may rupture spontaneously or by amniotomy.The person responsible for administering the anesthesia would be responsible for determining the level of anesthesia.Although some clients may sleep after an epidural, the client normally remains conscious while under the influence of regional anesthesia, such as an epidural block. Assessing the level of consciousness, although important for any client, is not the priority following epidural anesthesia.

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? variable decelerations late decelerations fetal heart rate accelerations persistent fetal bradycardia

fetal heart rate accelerations Fetal heart rate accelerations of at least 15 beats/minute for at least 15 seconds suggest adequate uteroplacental-fetal perfusion. Persistent fetal bradycardia may indicate hypoxia, arrhythmia, or umbilical cord compression. Variable decelerations also suggest umbilical cord compression. Late decelerations may reflect decreased blood flow and oxygen to the intervillous spaces during contractions.

A nurse recognizes that labor is divided into how many stages? five three two four

four Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum. The first stage is divided into three phases: early, active, and transition.

A client is admitted in early active labor at 39 weeks' gestation with intact membranes. When assessing the fetal heart rate, the nurse locates the heart sounds above the client's umbilicus at midline. The nurse should further confirm that the fetus is lying in which position? frank breech cephalic face transverse

frank breech When the fetus is in a breech position, the fetal heart rate most often is located above the umbilicus because the fetal heart is near the top of the mother's uterus. The heart of a fetus in the cephalic position is typically located on either the left or the right side of the client's uterus. Also, because the fetal heart typically is located in the lower portion of the mother's uterus, the sounds would be heard below the umbilicus. With a face presentation, fetal heart sounds are typically located on either the left or the right side of the client's uterus; in addition, because the fetal heart typically is located in the lower portion of the mother's uterus, the sounds would be heard below the umbilicus. When the fetus is in a transverse position, the fetal heart sounds typically would be located below the umbilicus and in the midline.

The nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage? heart rate 120 beats/minute, respiratory rate 8 breaths/minute, blood pressure 85/55 mmHg, oxygen sat 88% heart rate 80 beats/minute, respiratory rate 18 breaths/minute, blood pressure 95/65 mmHg, oxygen sat 84% heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 85/55 mmHg, oxygen sat of 99% heart rate 50 beats/minute, respiratory rate 28 breaths/minute, blood pressure 120/80 mmHg, oxygen sat 92%

heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 85/55 mmHg, oxygen sat of 99% When acute blood loss occurs, compensatory mechanisms result in changes in vital signs. Increased respiratory rate is the earliest sign of the body trying to increase oxygenation. Tachycardia (heart rate greater than 100 beats/minute, depending on the client's baseline) is evidence of an attempt to increase cardiac output in response to decreased preload and oxygen carrying capacity. A later sign is hypotension, which is evidence that the increase in heart rate and other compensatory mechanisms are failing to maintain perfusion pressure. With acute blood loss, oxygen saturation is not affected. Although oxygen carrying capacity is decreased due to loss of hemoglobin from the intravascular space, each remaining hemoglobin molecules will be fully saturated with oxygen in the absence of a respiratory problem. Therefore, the client can be experiencing tissue hypoxia, but the oxygen saturation will appear normal.

A primigravid client in active labor has just received an epidural block for pain. After administration of the epidural block, the nurse should assess the client for which condition? hyperreflexia uterine relaxation spinal headache hypotension

hypotension One of the most common maternal side effects after epidural anesthesia is hypotension. Therefore, the blood pressure must be assessed frequently after administration of this type of anesthesia. Other side effects include bladder distention, a prolonged second stage of labor, pruritus, nausea and vomiting, and delayed respiratory depression.Spinal headache may be an adverse effect of spinal anesthesia, but it is much less common with an epidural anesthetic.Hyperreflexia is not an adverse effect of epidural anesthesia.Uterine relaxation is associated with general anesthesia not epidural anesthesia.

The nurse is caring for a client at 36 weeks' gestation with a temperature of 101.2°F (38.4°C). Examination indicates that the client is leaking amniotic fluid. What is the nurse's priority concern based on these findings? urinary tract infection intrauterine infection group B Streptococcus colonization stress response to labor

intrauterine infection Premature membrane rupture creates an open port for intrauterine infection, indicated by an elevated temperature. The client doesn't exhibit common symptoms that would indicate a urinary tract infection. Fever and premature rupture of membranes aren't normal findings in labor. Group B strep colonization has no outward symptoms.

A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? active phase transitional phase latent phase expulsive phase

latent phase The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client? left lateral right lateral prone supine

left lateral The fetal heart rate monitoring strip shows late decelerations, which indicate uteroplacental circulatory insufficiency and can lead to fetal hypoxia and acidosis if the underlying cause is not corrected. The client would be turned onto her left side to increase placental perfusion and decrease contraction frequency. In addition, the intravenous fluid rate may be increased and oxygen administered. The right lateral, supine, and prone positions do not increase placental perfusion.left lateral

Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? feelings of relief numbness of the legs excitement loss of control

loss of control Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts.

A client in labor is experiencing intense uterine contractions that last between 60 and 90 seconds and occur every 2 minutes. The client is dilated to 8 cm. Which is the most appropriate nursing intervention? maintaining eye contact to help client stay focused leaving the room to get the nurse midwife or physician encouraging client to push with the next contraction applying external fetal monitor to monitor contractions

maintaining eye contact to help client stay focused When a client in labor is experiencing intense contractions that last between 60-90 seconds and occur every 2 minutes and the client is 8 cm dilated, the client is in the transitional phase of labor. During this phase it is important to stay with the client and maintain eye contact to help the client stay focused. Placement of the external fetal monitor to monitor contractions should have occurred in the active phase of labor. The client should not be encouraged to push as the client is not yet fully dilated to 10 cm.

A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority? assisting client to empty her bladder assessing vital signs assisting client to left lateral position massaging the uterus

massaging the uterus If uterine atony is noted, uterine massage should be performed to decrease the risk of postpartum hemorrhage. This intervention takes priority. If the uterus is displaced from midline, assist the client to empty her bladder. Vital signs should be taken every 15-30 minutes but the priority action is to address the uterine atony. A position change is not indicated.

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia? maternal hypotension maternal tachycardia maternal oliguria fetal tachycardia

maternal hypotension As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, and fetal and maternal bradycardia (not tachycardia). Although the client may experience some postpartum urine retention, maternal oliguria isn't associated with epidural anesthesia.

The nurse is caring for a client in labor. How would the nurse report the frequency of each contraction? timing the length of one contraction and averaging the length of another measuring the length of time from the start of one contraction to the start of the next asking the client how each contraction feels and document the differences with contractions palpating the top of the uterus during each contraction for strength

measuring the length of time from the start of one contraction to the start of the next To determine the frequency of contractions, the nurse should time one contraction to the next by the beginning of one contraction and ending at the beginning of the next. Timing the length of one contraction and then another would determine the duration. Palpating the top of the uterus determines strength of the contraction. Asking the client to describe the contraction does not determine the frequency of each contraction.

While waiting for the placenta to deliver, the nurse should not take any action before which action has occurred? asking the client to push down forcefully reaching into the uterus with sterile gloves massaging the fundus firmly observing for signs of placental separation

observing for signs of placental separation The best course of action is to wait for signs of placental separation, such as lengthening of the umbilical cord, a slight gush of dark blood, and a change in the contour of the fundus from discoid to globular. Pulling on the cord before the placenta is delivered may cause inversion of the uterus.After separation occurs, the client can be asked to bear down.Massaging the fundus is not helpful to ensure placental separation.Reaching into the uterus is done only when the placenta does not separate, necessitating manual removal. Doing so can lead to infection or uterine trauma.

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? terbutaline magnesium sulfate methergine oxytocin

oxytocin An epidural can slow contractions, so many clients will need to have oxytocin to maintain contraction strength. Magnesium sulfate and terbutaline are tocolytic medications to decrease contractions, and methergine is used for postpartum hemorrhage.

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? prostaglandin gel 0.5 mg oxytocin 30 units in 500 ml D5W misoprostol 50 mcg dinoprostone 10 mg

oxytocin 30 units in 500 ml D5W A Bishop score evaluates cervical readiness for labor based on five factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using oxytocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft and the presenting part is at a -1 to 0 position. Prostaglandin gel, misoprostol, and dinoprostone are all cervical ripening agents, and the doses are accurate; however, cervical ripening has already taken place.

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 sexually transmitted disease Rh incompatibility between mother and fetus maternal intrauterine infection

passage of meconium by the fetus Greenish-colored amniotic fluid is caused by the passage of meconium, usually secondary to a fetal insult during labor. Meconium passage also may be related to an intact gastrointestinal system of the neonate, especially those neonates who are full term or of postdate gestational age. Amnioinfusion may be used to treat the condition and dilute the fluid. Cloudy amniotic fluid is associated with an infection caused by bacteria or a sexually transmitted disease. Severe yellow-colored fluid is associated with Rh incompatibility or erythroblastosis fetalis.

A nurse is caring for a 28-week gestation primigravida client in the labor and birth area. The client reports that she has not felt fetal movement in more than 3 days. Ultrasonography reveals intrauterine fetal demise. Which laboratory finding is indicatives of a potentially serious complication? increased white blood cell (WBC) count prolonged prothrombin time (PT) negative D-dimer decreased red blood cell (RBC) count

prolonged prothrombin time (PT) Intrauterine fetal demise increases the occurrence of disseminated intravascular coagulation (DIC). An indicator that assists in the diagnosis of DIC is prolonged PT. The D-dimer is expected to be negative. Decreased RBC and increased WBC are of concern but are not of higher priority than the prolonged PT.

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 pulmonary gastrointestinal cardiovascular

pulmonary The shake test helps determine the maturity of the fetal pulmonary system. The test is based on the fact that surfactant foams when mixed with ethanol. The more stable the foam, the more mature the fetal pulmonary system. Although the shake test is inexpensive and provides rapid results, problems have been noted with its reliability. Therefore, the lecithin-sphingomyelin ratio is usually determined in conjunction with the shake test.

A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change from slow chest breathing to which breathing technique? slow abdominal breathing rapid, shallow chest breathing deep chest breathing rapid pant-blow breathing

rapid, shallow chest breathing The psychoprophylaxis method of childbirth suggests using slow chest breathing until it becomes ineffective during labor contractions, then switching to shallow chest breathing (mostly at the sternum) during the peak of a contraction. The rate is 50 to 70 breaths/min. Deep chest breathing is appropriate for the early phase of labor, in which the client exhibits less frequent contractions. When transition nears, a rapid pant-blow pattern of breathing is used. Slow abdominal breathing is very difficult for clients in labor.

Which technique to promote active relaxation would the nurse include in the teaching plan for a 16-year-old primigravid client in early labor? relaxing uninvolved body muscles during uterine contractions breathing rapidly and deeply between contractions focusing on an object in the room during the contractions practicing being in a deep, meditative, sleeplike state

relaxing uninvolved body muscles during uterine contractions Childbirth educators use various techniques and methods to prepare parents for labor and birth. Active relaxation involves relaxing uninvolved muscle groups while contracting a specific group and using chest breathing techniques to lift the diaphragm off the contracting uterus. A deep, meditative, sleeplike state is a form of passive relaxation. Focusing on an object in the room is part of Lamaze technique for distraction. Breathing rapidly and deeply can lead to hyperventilation and is not recommended.

The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. What is the nurse's priority intervention? administering oxygen at 10L per non-rebreather mask notifying the healthcare provider repositioning the client to the other side administering a fluid bolus

repositioning the client to the other side Variable decelerations are caused by umbilical cord compression. These can occur with or without a contraction. Positioning the client on her side would provide optimal oxygenation to the fetus. Calling the healthcare provider without repositioning the client first would be inappropriate. Giving oxygen and fluid may be the next steps if the fetus is showing more signs of stress.

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? respiratory distress syndrome pulmonary hypertension congenital anomalies meconium aspiration syndrome

respiratory distress syndrome Respiratory distress syndrome is more common in neonates born by cesarean section than in those born vaginally. During a vaginal birth, pressure is exerted on the fetal chest, which aids in the fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with a cesarean birth. Congenital anomalies are not more common with cesarean birth. Pulmonary hypertension occurs more commonly in infants with meconium aspiration syndrome, congenital diaphragmatic hernia, respiratory distress syndrome, or neonatal sepsis, not with cesarean birth. Meconium aspiration syndrome occurs more commonly with vaginal birth, postterm neonate, and prolonged labor, not with cesarean birth.

The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which position? prone side-lying lithotomy hands and knees

side-lying Lumbar epidural anesthesia is usually administered with the client in a sitting or a left side-lying position with shoulders parallel and legs slightly flexed. These positions expose the vertebrae to the anesthesiologist. Paracervical and local anesthetics are usually administered with the client in the lithotomy position. The hands and knees or prone positions are not used for anesthesia administration.

The nurse is caring for a client who was admitted to the labor and birth department in preterm labor at 30 weeks' gestation. The nurse anticipates which medication will be given to help manage preterm labor? betamethasone prostaglandin terbutaline indomethacin

terbutaline Terbutaline reduces the frequency and intensity of uterine contractions by stimulating B2 receptors in the uterine smooth muscle. It is the drug of choice to inhibit labor. Indomethacin is an anti-inflammatory. Prostaglandins would induce cramping. Betamethasone, a synthetic corticosteroid, is administered to the mother to stimulate fetal pulmonary surfactant.

A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them? the client's best friend, who's the sperm donor the court system, because the client isn't married and is legally responsible for the neonate the client's partner the client's parents, because they're blood relatives

the client's partner A legal document stating that the client's partner is the healthcare surrogate for the client and the fetus authorizes the partner to make decisions on behalf of the client or the fetus if the client isn't able to do so. Before insemination, a donor signs a legal document waiving rights to the child; therefore, the donor has no authority to make healthcare decisions on behalf of the client or the fetus. Pregnancy at any age results in emancipation; parents don't have rights to make healthcare decisions for pregnant adolescents. The court system wouldn't make the decision if the client has designated a legal healthcare surrogate.

A client who is in her third trimester presents at the labor and delivery triage area with a history of a fall. She has bruising on her back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to the social worker on call. the physician on call. a lawyer. Women in Distress (local provincial/territorial, regional or aboriginal shelter).

the social worker on call. The social worker on call knows how to make a referral to authorities without violating the client's rights. The nurse does not need to contact the physician because the physician would also refer the client to the social worker. The nurse does not have the right to refer the client to Women in Distress, an organization that shelters victims of abuse, without the client's permission. It is not appropriate for the nurse to refer the client to a lawyer.

During the fourth stage of labor, the client should be assessed carefully for uterine atony. placental expulsion. complete cervical dilation. umbilical cord prolapse.

uterine atony. Uterine atony should be carefully assessed during the fourth stage. The second stage of labor begins with complete cervical dilation and ends with birth. The third stage begins immediately after birth and ends with the separation and expulsion of the placenta. Immediately after delivery, the placenta is evaluated carefully for completeness, and the client is assessed for excessive bleeding or a relaxed uterus. After delivery of the placenta is the fourth stage and assessing for relaxed uterus helps determine uterine atony. Umbilical cord prolapse, displacement of the umbilical cord to a position at or below the fetus's presenting part, occurs most commonly when amniotic membranes rupture before fetal descent. The client should be assessed for a visible or palpable umbilical cord in the birth canal, violent fetal activity, or fetal bradycardia with variable deceleration during contractions. The presence of umbilical cord prolapse requires an emergency delivery.

The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which intervention should the nurse recommend at this time? walking around in the hallway lying in the left lateral recumbent position sitting in a comfortable chair for a period of time resting in the right lateral recumbent position

walking around in the hallway Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single-room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? use of protective goggles during a caesarean birth wearing of sterile gloves to bathe a neonate at 2 hours of age disposal of used scalpel blades in a puncture-resistant container placement of bloody sheets in a container designated for contaminated linens

wearing of sterile gloves to bathe a neonate at 2 hours of age One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.

The nurse is caring for a client that has been in labor for 6 hours. When does the nurse document that the client has ended the third stage of labor? when the client is fully dilated and effaced when the client is 2 hours postpartum when the neonate has been born when the placenta has been birthed

when the placenta has been birthed The third stage of labor is indicated by the birth of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth.