labor and delivery

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication 2. Give the medication slowly during the peak of the next contraction 3. Hold until contractions are occurring at least every 4 minutes for an hour 4. Withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication

2. Give the medication slowly during the peak of the next contraction Administration of IV narcotics (eg, nalbuphine, butorphanol, meperidine) during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth (Option 2). Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief. Educational objective: IV narcotics administered to laboring women can cause fetal sedation and subsequent respiratory depression at birth. Administering IV narcotics at the peak of contractions reduces the amount of narcotic that crosses the placental barrier and affects the fetus.

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? 1. Complete hourly pain assessments using a numeric pain scale 2. Document that the client appears to be experiencing minimal pain 3. Monitor for nonverbal signs of ineffective coping with labor 4. Recognize that the client's stoicism is ineffective coping with labor

3. Monitor for nonverbal signs of ineffective coping with labor Developing cultural competence (ie, understanding, attitudes, and abilities acquired to meet the needs of culturally diverse clients) helps the nurse provide culturally sensitive labor support and pain management. Clients from Japanese culture may value silence and nonverbal communication over overt forms of communication. It may be considered culturally appropriate to be stoic (ie, showing admirable patience) during labor, and pain may be accepted as a part of the process. Therefore, the client may not desire pharmacologic pain management. In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping (Option 3). Clients may report a high pain score, yet be coping effectively and not desire pharmacologic pain relief. Educational objective: A client's cultural background may affect expression of pain during labor. In Japanese culture, silence and nonverbal communication may be valued over overt forms of communication. The nurse should assess the client's coping and monitor for nonverbal cues of ineffective coping (eg, writhing, screaming, panicking).

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply. 1. "Do you feel like the contractions are getting stronger?" 2. "Does anything you do make the pain better?" 3. "Have you lost your mucous plug?" 4. "How frequent are the contractions?" 5. "Where do you feel the contraction pain most?"

1. "Do you feel like the contractions are getting stronger?" 2. "Does anything you do make the pain better?" 4. "How frequent are the contractions?" 5. "Where do you feel the contraction pain most?" True labor is defined as contractions that cause progressive cervical change over time. Probable signs of labor are identified by assessing the timing and intensity of contractions, the success of comfort measures in relieving the pain, and the location of the pain (Options 2 and 5). Consistent, intense contractions that get stronger and closer together (more frequent over time) and are associated with lower back discomfort that radiates to the abdomen are indicative of true labor (Options 1 and 4). If a woman is experiencing Braxton Hicks contractions (ie, "false labor"), the nurse should provide encouragement and education about signs of labor and suggest comfort measures. Comfort measures relieve maternal anxiety, increase coping, and encourage normal progression of labor. The nurse may suggest walking, taking a warm bath, resting in a lateral position, having a snack, staying hydrated, and voiding often. Educational objective:True labor is defined as contractions that cause progressive cervical change over time. Consistent, intense contractions that get stronger and closer together and are associated with lower back discomfort that radiates to the abdomen are indicative of probable labor.

The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion. When describing interventions, which statement by the nurse indicates a need for further education? 1. "I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected." 2. "I will establish a second IV line with an 18-gauge catheter." 3. "I will initiate serial blood pressure monitoring every 3-5 minutes." 4. "I will notify anesthesia and operating room staff of the client's condition immediately."

1. "I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected." Uterine inversion is a rare, obstetrical emergency that occurs after birth when the uterine fundus collapses (partially or completely) into the uterine cavity, causing sudden hemorrhage, severe pelvic pain, and hypovolemic shock. Successful manual replacement of the inverted uterus through the vaginal canal by the health care provider (HCP) is the first step in resolving the inversion and requires a soft, uncontracted uterus. Tocolytics (eg, terbutaline) or inhaled anesthetics may be needed to assist with uterine relaxation. Uterotonic medications (eg, oxytocin, carboprost) must be delayed or discontinued until after the HCP has corrected the inversion (ie, manual uterine replacement) (Option 1). After uterine replacement, uterotonics are administered to reinforce its location in the pelvis and control further bleeding. Educational objective: Uterine inversion is a postbirth complication in which the uterine fundus collapses into the uterine cavity, resulting in sudden hemorrhage and hypovolemic shock. Initially, a soft, uncontracted uterus is needed to correct the inversion (ie, manual uterine replacement), and uterotonic administration (eg, oxytocin) is delayed until after the uterus is replaced.

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? Select all that apply. 1. Abnormal or indeterminate fetal heart rate patterns 2. Delayed breast milk production 3. Placenta previa 4. Postpartum hemorrhage 5. Uterine tachysystole

1. Abnormal or indeterminate fetal heart rate patterns 4. Postpartum hemorrhage 5. Uterine tachysystole Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions (Option 1). Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin (Option 4). Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. Uterine tachysystole (ie, >5 contractions in 10 minutes) (Option 5) Educational objective:Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle and is used to induce or augment labor and to prevent postpartum hemorrhage (PPH). Oxytocin administration increases the risk of abnormal fetal heart rate patterns, emergency cesarean birth, uterine tachysystole, placental abruption, and uterine rupture. Prolonged administration increases the risk of water intoxication and PPH.

The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply. 1. Administer oxygen via a nonrebreather face mask 2. Change maternal position to the left side 3. Discontinue the oxytocin infusion 4. Notify the health care provider 5. Perform a nitrazine test

1. Administer oxygen via a nonrebreather face mask 2. Change maternal position to the left side 3. Discontinue the oxytocin infusion 4. Notify the health care provider The mnemonic VEAL CHOP may help nurses recall causes of fetal heart rate (FHR) changes noted on monitor tracings. A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point (nadir) after the contraction peak, and then gradually returns to baseline. Late decelerations indicate impaired fetal oxygenation associated with decreased uteroplacental perfusion (eg, due to maternal hypotension after epidural placement or uterine tachysystole). Chronic uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may also cause late decelerations. Nursing actions to improve fetal perfusion and oxygenation include: Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity (Option 3) Changing maternal position to the left side to relieve compression of the inferior vena cava. If the FHR tracing does not improve, a right-side position may be attempted (Option 2) Administering oxygen at 8-10 L/min via nonrebreather face mask to promote fetal oxygenation (Option 1) Giving prescribed IV bolus of lactated Ringer solution or normal saline to improve placental perfusion, especially during maternal hypotension Notifying the health care provider (Option 4) Educational objective:Late decelerations are evidence of impaired fetal oxygenation. Discontinuing the oxytocin infusion, changing maternal position, administering oxygen, and giving an IV fluid bolus are essential interventions.

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply. 1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 3. Assisting with artificial rupture of membranes 4. Initiating IV magnesium sulfate 5. Obtaining fetal heart tones once per shift

1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 4. Initiating IV magnesium sulfate Preterm labor (PTL) is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development (Option 1) Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs (Option 2) Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation (Option 4) Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained Educational objective:Preterm labor is progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate several interventions, including administration of IM antenatal glucocorticoids, antibiotics, and IV magnesium sulfate.

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client? 1. Administration of prophylactic antibiotics 2. Assessment of uterine contraction frequency 3. Collection of a clean-catch urine specimen 4. Vaginal examination to assess cervical dilation

1. Administration of prophylactic antibiotics Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive. If GBS status is unknown, antibiotics are typically indicated when membranes have been ruptured for ≥18 hours, maternal temperature is ≥100.4 F (38 C), or gestation is <37 weeks (Option 1). Educational objective:Group B Streptococcus (GBS) infection can be transmitted to the newborn during labor and birth and cause serious complications. Indications for prophylactic antibiotics during labor include maternal GBS-positive status or unknown GBS status with fever ≥100.4 F (38 C), preterm gestation, and/or prolonged rupture of membranes.

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take? 1. Apply gloves and assess perineal area 2. Initiate large-bore IV access 3. Notify anesthesia provider of client's request for epidural 4. Obtain fetal heart tones via Doppler

1. Apply gloves and assess perineal area Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth. Signs of imminent birth include involuntary pushing/bearing down with contractions, grunting, or report of sensations of having a bowel movement. If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part (Option 1). If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed actions (eg, contact provider, assess fetal heart tones, initiate IV access). Educational objective:Precipitous birth is defined as <3 hours of labor from contraction onset until birth. When a client arrives at the hospital in second-stage labor, the nurse rapidly assesses whether birth is imminent before performing other interventions.

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counterpressure to the client's sacrum during contractions 2. Encouraging the client to remain in bed during early labor 3. Positioning the client on the left side with pillows for support 4. Requesting that the nurse anesthetist administer epidural anesthesia

1. Applying counterpressure to the client's sacrum during contractions Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis). The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager) (Option 1). Educational objective:Fetal occiput posterior position may cause intense back pain during labor. Client comfort can be increased by applying counterpressure to the sacrum during contractions.

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place for all clients with preeclampsia. Side rails should be padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning suction equipment and supplemental oxygen should be available at the bedside (Option 4). During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L/min by facemask. Magnesium sulfate is a central nervous system (CNS) depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly during administration (Option 1). Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be immediately available (Option 2). Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors and the number of caregivers entering/exiting the client's room (Option 5). Educational objective:Magnesium sulfate is commonly prescribed to clients with severe preeclampsia to prevent seizures and is a central nervous system depressant. Safety measures for preeclampsia include seizure precautions and decreasing environmental stimuli.

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate? Select all that apply. 1. Assessing the fetal heart rate before and after the procedure 2. Checking the client's temperature every 2 hours 3. Informing the client she will feel a sharp pain during the procedure 4. Keeping the client in a supine position after the procedure 5. Noting the characteristics of the amniotic fluid

1. Assessing the fetal heart rate before and after the procedure 2. Checking the client's temperature every 2 hours 5. Noting the characteristics of the amniotic fluid Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure (Option 1). The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection (Option 5). Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2). Educational objective:When assisting with an amniotomy, the nurse should assess the fetal heart rate, note the characteristics of the amniotic fluid, and assist the client to an upright position after the procedure.

The graduate nurse (GN) is caring for a laboring client with epidural anesthesia. After the client pushes for 3 hours during the second stage of labor, the health care provider (HCP) decides to use forceps to assist the client to deliver secondary to maternal exhaustion. Which action by the GN requires the nurse preceptor to intervene? 1. Begins to apply fundal pressure when the HCP applies traction to forceps 2. Drains the client's bladder using a catheter before the placement of forceps 3. Notes the exact time the forceps are applied on a card for documentation in the birth record 4. Palpates for contractions and notifies the HCP when they are present

1. Begins to apply fundal pressure when the HCP applies traction to force An operative vaginal birth uses a vacuum extractor or forceps to shorten the second (pushing) stage of labor. Indications may be maternal (eg, exhaustion, cardiac or cerebrovascular disease) or fetal (eg, abnormal fetal heart rate, arrest of rotation). In a forceps-assisted birth, the health care provider (HCP) gently applies the blades to the sides of the fetal head and locks the handles in place. The HCP applies traction to the forceps during contractions to facilitate rotation and descent of the fetal head. The nurse should never apply fundal pressure during an operative vaginal birth because it may cause uterine rupture (Option 1). Educational objective:In an operative vaginal birth, forceps or a vacuum extractor is used to shorten the second (pushing) stage of labor. The nurse ensures that the client's bladder is empty, monitors for contractions, and documents the time that forceps or a vacuum extractor was applied. Fundal pressure should never be applied during this procedure or labor/birth.

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? 1. Bishop score of 10 2. Firm and posterior cervix 3. History of precipitous labor 4. Reactive nonstress test

1. Bishop score of 10 The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥6-8 usually indicates that induction will be successful (Option 1). Educational objective: The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. A score ≥6-8 in nulliparous women is associated with successful induction and subsequent vaginal birth.

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia 2. Fetal tachycardia with moderate variability 3. Increased anxiety and discomfort with contractions 4. Painful, strong contractions every 3-4 minutes

1. Cessation of contractions and maternal tachycardia Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. Educational objective:Clients attempting vaginal birth after cesarean have a slightly increased risk for uterine rupture. Signs of uterine rupture may include abnormal fetal heart rate pattern (ie, decelerations, decreased variability, bradycardia), loss of fetal station, constant abdominal pain, cessation of uterine contractions, and maternal tachycardia.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds 2. Contraction frequency of every 3 minutes 3. Contraction intensity of 45 mm Hg 4. Uterine resting tone of 10 mm Hg

1. Contraction duration of 95 seconds Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. Educational objective: Uterine contractions during labor dilate and efface the cervix and cause descent of the fetus. The contraction duration should not exceed 90 seconds or occur less than 2 minutes apart. Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply. 1. Administer oxytocin through the primary IV line 2. Assess the uterine contraction pattern 3. Initiate continuous fetal heart rate monitoring 4. Place IV oxytocin on an electronic infusion pump 5. Titrate oxytocin to achieve cervical dilation of 1 cm every 2 hours

2. Assess the uterine contraction pattern 3. Initiate continuous fetal heart rate monitoring 4. Place IV oxytocin on an electronic infusion pump Oxytocin is a high-alert medication commonly used for labor induction or augmentation. It should be administered via an electronic infusion pump (Option 4), which decreases medication errors, provides for accurate dosing, and prevents maternal hypotension associated with rapid oxytocin bolus. The nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes during the first stage of labor and every 5 minutes during the second stage (Option 2). Continuous electronic fetal heart rate monitoring, not intermittent auscultation, is necessary (Option 3). The nurse should also monitor maternal intake and output to identify fluid retention, which precedes water intoxication, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions, and death. Educational objective: Oxytocin is a high-alert medication requiring precise administration via a secondary IV line on an electronic infusion pump and frequent maternal/fetal assessment. The medication is titrated to achieve an adequate contraction pattern without causing uterine tachysystole or fetal distress.

A pregnant client comes to the labor and delivery unit stating, "My water just broke at home." On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure 2. Assist the client to the knee-chest position 3. Perform Leopold maneuvers 4. Perform the McRoberts maneuver

2. Assist the client to the knee-chest position Umbilical cord prolapse occurs when the umbilical cord slips below the presenting fetal part and causes cord compression and impaired fetal oxygenation. A loop of cord may be palpated during vaginal examination or visualized protruding from the vagina. An emergency cesarean birth is usually required unless vaginal birth is imminent and considered safe by the health care provider (HCP). Positioning the client on the hands and knees with the buttocks elevated above the head (knee-chest position) or in the Trendelenburg position relieves pressure on the compressed cord (Option 2). The nurse may also use a sterile, gloved hand to lift the presenting part off the cord. Other actions include administration of oxygen and IV fluids. Educational objective: A client with a prolapsed umbilical cord should be placed in the knee-chest or Trendelenburg position to relieve pressure on the cord until emergency birth is possible.

​​​​​​​​​​​​​​The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action? 1. Document fetal presentation as breech 2. Document fetal presentation as cephalic 3. Elevate the fetal presenting part away from the prolapsed cord 4. Request that the health care provider confirm fetal presentation

2. Document fetal presentation as cephalic The nurse is most likely palpating the diamond-shaped anterior fontanelle of the fetal head, which is in cephalic (ie, head down) presentation. Therefore, the nurse should document the fetal presentation as cephalic. The posterior fontanelle is triangular and separated from the anterior fontanelle by the sagittal suture. By identifying the location of these fetal skull landmarks, an experienced examiner can determine the fetal head position, or the direction the occiput is facing. Educational objective:Fetal head position can be determined by the sutures and fontanelles (eg, diamond-shaped anterior fontanelle) of the fetal skull.

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply. 1. Assist maternal pushing efforts by applying fundal pressure during each contraction 2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 4. Prepare for a forceps-assisted birth 5. Request additional assistance from other nurses immediately

2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 5. Request additional assistance from other nurses immediately Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. Shoulder dystocia lasting ≥5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes (eg, hypoxia, nerve injury, death). When shoulder dystocia occurs, the primary nursing interventions include: Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) (Option 2) Verbalizing passing time to guide decision-making by the health care provider (eg, "two minutes have passed") Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) (Option 3) Requesting additional help from staff (eg, nurses, neonatologist) immediately (Option 5) Educational objective: Shoulder dystocia occurs when the anterior shoulder becomes wedged behind or under the maternal symphysis pubis. The nurse should document the timing of events (eg, birth of fetal head), verbalize passing time, perform McRoberts maneuver, apply suprapubic pressure, and request additional assistance.

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene? 1. Documenting a positive nitrazine test result when the test strip turns blue 2. Donning nonsterile gloves and using soluble gel for vaginal examination 3. Palpating the client's abdomen before applying external fetal monitors 4. Providing the client with a variety of clear liquids to drink

2. Donning nonsterile gloves and using soluble gel for vaginal examination The nurse should use a sterile glove during vaginal examination in the presence of ruptured membranes to prevent infection. Use of nonsterile gloves and instruments during vaginal examinations increases the risk of infection in the laboring client or fetus (eg, chorioamnionitis). Educational objective:Vaginal examinations of the laboring client with ruptured membranes should be performed using a sterile glove to decrease the risk of infection (eg, chorioamnionitis) to the client and fetus. Other labor admission interventions include application of external fetal monitoring and performance of a nitrazine pH test to determine if membranes have ruptured.

Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? Select all that apply. 1. Avoid discussing the adoption details until after the birth 2. Encourage the birth mother to hold the newborn 3. Notify other staff who may interact with the client of the adoption plan 4. Offer the birth mother a chance to say goodbye to the newborn 5. Use phrases that illustrate adoption as a decision of love, not abandonment

2. Encourage the birth mother to hold the newborn 3. Notify other staff who may interact with the client of the adoption plan 4. Offer the birth mother a chance to say goodbye to the newborn 5. Use phrases that illustrate adoption as a decision of love, not abandonment Adoption, the decision to relinquish care of a child to another, is complex and involves a variety of emotional and psychosocial responses from clients. The nurse should encourage the birth mother to create memories with her newborn to facilitate the grieving process. This may include holding the newborn, taking pictures, and naming the newborn (Option 2). When the time comes, offering the client a chance to say goodbye to the newborn supports the birth mother in her emotional transition and acknowledges the importance of her relationship with the newborn (Option 4). The nurse protects the client by notifying relevant staff of the decision, which prevents unintended, potentially hurtful remarks (Option 3). Substituting phrases like "giving up" and "giving away" with "choosing adoption" reinforce adoption as a loving decision and not neglect or abandonment (Option 5). Educational objective :Caring for a client who plans to relinquish a newborn to an adoptive family involves giving the client an opportunity to express emotions, be involved in decision-making, interact with the newborn, make memories, and feel reassured that the decision is one of love and not abandonment.

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first? 1. Administer IV ondansetron 2. Apply oxygen via face mask 3. Obtain blood pressure 4. Perform vaginal examination

3. Obtain blood pressure An epidural block (a form of regional anesthesia) can provide effective pain relief during labor; however, it also inhibits the sympathetic nervous system (SNS). SNS inhibition causes peripheral vasodilation, which may produce significant hypotension (ie, systolic blood pressure <100 mm Hg, ≥20% decrease from baseline). If a client exhibits hypotensive symptoms (eg, lightheadedness, nausea) while receiving epidural anesthesia, the nurse should first assess blood pressure to confirm the presence of hypotension before intervening (Option 3). If hypotension is present, initial nursing interventions include administering an IV fluid bolus to increase blood volume and positioning the client in the left lateral position to alleviate pressure on the vena cava. Educational objective: Epidural blocks can inhibit the sympathetic nervous system, causing peripheral vasodilation leading to hypotension. Hypotensive symptoms include lightheadedness and nausea. The nurse should first assess blood pressure and then intervene (eg, IV fluids, left lateral positioning, oxygen) as appropriate.

The nurse reviews the laboratory results of a laboring client who is requesting epidural anesthesia. Which value is the priority to report to the anesthesia provider prior to epidural placement? Click on the exhibit button for additional information. Laboratory results Blood group O Rh factor Negative Hematocrit 32% (0.32) Hemoglobin10 g/dL (100 g/L) WBCs15,000/mm3 (15 × 109/L) Platelets90,000/mm3 (90 × 109/L) 1. Blood type and Rh 2. Hemoglobin 3. Platelet count 4. White blood cell count

3. Platelet count Epidural anesthesia, an elective procedure for pain relief in labor, may be contraindicated in clients with uncorrected hypotension, coagulopathies (eg, extremely low platelets, clotting disorders), or infection at the epidural site. Low platelets in pregnancy may occur as part of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) or for idiopathic reasons (eg, gestational thrombocytopenia). Clients with low platelets (especially <100,000/mm3 [100 × 109/L]) are at risk for bleeding at the epidural puncture site, which may lead to hematoma formation, spinal cord compression, and subsequent neurologic dysfunction (Option 3). (Option 1) Blood type and Rh factor have no effect on epidural anesthesia. (Option 2) Hemoglobin <11 g/dL (110 g/L) or hematocrit <33% (0.33) defines anemia in the first and third trimesters of pregnancy. These trimester-specific values account for the physiologic anemia of pregnancy caused by the dilution of blood due to increased plasma volume. However, anemia is not a contraindication to epidural anesthesia. (Option 4) White blood cell count in nonpregnant clients is normally 5,000-10,000/mm3 (5.0-10.0 x 109/L) but may be elevated up to 15,000/mm3 (15.0 x 109/L) in pregnant clients, usually due to an increase in neutrophils. This client's count is within the normal range for pregnancy. Educational objective:Contraindications to epidural anesthesia include uncorrected maternal hypotension, coagulopathies (eg, low platelets), and infection at the epidural insertion site.

Four clients in labor are requesting pain relief. The nurse understands that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time? 1. Multipara at 6 cm dilation with recent heroin use 2. Multipara at 9 cm dilation with an urge to push 3. Nullipara at 3 cm dilation desiring to ambulate 4. Nullipara at 7 cm dilation moaning with contractions

4. Nullipara at 7 cm dilation moaning with contractions Opioid agonist-antagonist medications used in labor include butorphanol tartrate (Stadol) and nalbuphine hydrochloride (Nubain). Maternal adverse effects include sedation, dizziness, and nausea. Butorphanol tartrate crosses the placental barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours. If given near the time of birth, there is a risk for newborn respiratory depression, which may require naloxone (Narcan) to reverse the effects. IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to wear off before the birth. IV opioids are also best for clients in active labor or those with a well-established contraction pattern because opioid administration may slow labor progression in the latent phase (Option 4). Educational objective: Opioid agonist-antagonist medications (eg, butorphanol tartrate [Stadol]) are most appropriate for clients in active labor with no contraindications (eg, imminent birth, opioid dependence). Opioids have maternal adverse effects (eg, sedation, dizziness, slow labor progression) and may cause newborn respiratory depression.

A client gives birth within an hour of arriving at the labor and delivery unit and delivers the placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline and boggy. Which action should the nurse take first? 1. Check for pooled blood under buttocks 2. Increase IV oxytocin infusion rate 3. Monitor blood pressure and pulse 4. Perform firm fundal massage

4. Perform firm fundal massage After delivery of the placenta, the uterus begins the process of involution. The uterus should be firmly contracted, midline, and at or slightly below the umbilicus. A boggy uterus indicates uterine atony, a state in which the uterus fails to contract adequately and compress vessels at the placental detachment site. This may lead to excessive blood loss and clots. The initial nursing action for uterine atony with a midline fundus is fundal massage, which stimulates contraction of the uterine smooth muscle (Option 4). If the uterus becomes firm with massage, the nurse should continue to monitor uterine tone, position, and lochia at least every 15 minutes in the initial hour after birth. Educational objective:After placenta delivery, the fundus should be firm, midline, and at or slightly below the umbilicus. The initial nursing action to correct uterine atony with a midline, boggy uterus is fundal massage.

The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate? 1. Administering a tocolytic 2. Initiating fundal pressure during a contraction 3. Obtaining the vacuum extractor 4. Pressing downward on the symphysis pubis

4. Pressing downward on the symphysis pubis Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size. The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder) (Option 4). Educational objective:Shoulder dystocia occurs when the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse should be prepared to perform McRoberts maneuver and apply suprapubic pressure.

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia 2. Hydrotherapy 3. IV narcotics 4. Pudendal nerve block

4. Pudendal nerve block A pudendal nerve block infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the health care provider. It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor (Option 4). In clients without an epidural, pudendal blocks may be used in preparation for forceps-assisted birth or laceration repair. (Option 1) An epidural can be administered in the first or early second stage of labor but may not be a feasible option in late second stage when birth is imminent. A multiparous client may give birth before the epidural can be administered or before the epidural takes adequate effect (20-30 minutes). Educational objective: A pudendal nerve block can provide pain relief for clients experiencing perineal pressure in the late second stage of labor. It may also be used in preparation for forceps-assisted birth or laceration repair in clients without an epidural. It does not provide relief of contraction pain.

The nurse is monitoring a client who is 6 cm dilated with recurrent variable decelerations on the fetal heart rate monitor. The health care provider (HCP) places an intrauterine pressure catheter and prescribes an amnioinfusion. After the amnioinfusion bolus is complete, which assessment finding should the nurse report to the HCP immediately? Click the exhibit button for additional information. 1. Cervix is 8 cm dilated and 100% effaced, with fetal presenting part at +1 station 2. Contractions are every 3 minutes and 60-80 seconds each 3. Fetal heart rate baseline is 155/min with early decelerations and moderate variability 4. Uterine resting tone baseline has increased to 45 mm Hg and perineal pads are dry

4. Uterine resting tone baseline has increased to 45 mm Hg and perineal pads are dry An amnioinfusion is a transvaginal infusion of isotonic fluids through an intrauterine pressure catheter to compensate for low amniotic fluid (eg, oligohydramnios, ruptured membranes) in the uterus. During labor, an amnioinfusion is indicated to relieve persistent, recurrent variable decelerations caused by umbilical cord compression. Uterine overdistension is a potential complication due to infusion of too much fluid. Therefore, the nurse should use an infusion pump to control the rate and amount of fluid, evaluate for fluid return frequently, and monitor uterine resting tone closely. If baseline uterine resting tone is elevated (normal: ≤20 mm Hg) and minimal to absent fluid return is noted, the nurse should pause the infusion and notify the health care provider immediately (Option 4). Educational objective:An amnioinfusion is a transvaginal infusion of isotonic fluids through an intrauterine pressure catheter to compensate for low amniotic fluid and relieve recurrent variable decelerations. The nurse should monitor for an elevated uterine resting tone baseline and minimal to absent fluid return, which may indicate uterine overdistension.

What is an appropriate nursing intervention after the birth of a newborn with anencephaly? 1. Instruct the parents that visitors should be restricted 2. Provide information to the parents about genetic counseling 3. Refer the parents to a perinatal loss support group(10%) 4. Wrap the newborn in warm blankets for the parents to hold

4. Wrap the newborn in warm blankets for the parents to hold Anencephaly is a severe neural tube defect (NTD) resulting in little to no brain tissue or skull formation in utero. Many newborns with anencephaly are stillborn, and those born alive are not compatible with life. Comfort care for the newborn and emotional support for the family is priority at the time of birth. Drying, bundling, and placing the newborn skin-to-skin provides warmth, and administering oxygen may decrease discomfort to the newborn. Allowing the family to hold the newborn will assist with the grieving process. Educational objective:Anencephaly is a severe neural tube defect resulting in little to no brain tissue or skull formation in utero. The newborn may be stillborn or born alive, although death occurs shortly thereafter. Nurses should facilitate a therapeutic environment for grieving parents and provide newborn comfort care such as warmth and oxygen.

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place.

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The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain? 1. The client has a history of three previous cesarean births 2. The client has a signed consent form for a cesarean hysterectomy 3. The client has removed all metal jewelry and contact lenses 4. The client has two 18-gauge IVs and a blood type and crossmatch

4. The client has two 18-gauge IVs and a blood type and crossmatch Placenta accreta is a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. Prenatal ultrasound usually detects placenta accreta, although detection can rarely occur after birth when the placenta is adherent (ie, retained placenta). A cesarean birth before term gestation at a facility with adequate resources (eg, blood products, intensive care unit) is recommended for clients with placenta accreta. The major complication of placenta accreta is life-threatening hemorrhage, which occurs during attempted placental separation. At least two large-bore IVs (eg, 18-gauge) and a blood type and crossmatch are priority concerns in case blood transfusions are necessary (Option 4). Educational objective: Placenta accreta occurs when the placenta adheres abnormally to the myometrium; attempted separation can result in life-threatening hemorrhage. Priority concerns include presence of at least two large-bore IVs and available blood products should hemorrhage occur.

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply. 1. Contractions that increase in frequency 2. Contractions that lessen after resting 3. Increased blood-tinged, mucoid vaginal discharge 4. Pain in lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation

1. Contractions that increase in frequency 4. Pain in lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation A key indicator of true labor is the progressive effacement and dilation of the cervix (Option 5). Contractions in true labor are regular, and increase in frequency, duration, and intensity (Option 1). The pain may initially start in the lower back and radiate to the abdomen (Option 4). Educational objective:During true labor, contractions increase in frequency, duration, and intensity over time, resulting in progressive dilation and effacement of the cervix. Clients in true labor often experience discomfort in the lower back that radiates to the abdomen with contractions. Contractions associated with true labor do not lessen or dissipate with comfort measures.

(Option 3) Variable decelerations are abrupt decreases in the FHR (ie, <30 seconds from onset to nadir) and at least 15 beats/min below baseline for ≥15 seconds to <2 minutes. Variables are usually correctable with maternal position change to relieve umbilical cord compression. If recurrent/prolonged, variable decelerations can impair fetal oxygenation over time.A pregnant client is brought to the emergency department by ambulance after her water broke. She is screaming and bearing down with every contraction. Which of the following assessment questions are essential to ask in preparation for the birth and possible newborn resuscitation? Select all that apply. 1. "Did you receive the influenza vaccine during pregnancy?" 2. "Do you take any medications or illicit drugs?" 3. "How many babies are you expecting?" 4. "What color was the fluid when your water broke?" 5. "When is your due date?"

2. "Do you take any medications or illicit drugs?" 3. "How many babies are you expecting?" 4. "What color was the fluid when your water broke?" 5. "When is your due date?" When a pregnant client arrives at the hospital and birth is imminent, the nurse should collect a brief, focused history to elicit essential information relevant to potential newborn resuscitation, including: Recent medication or illicit drug use (especially within the last 4 hours): Certain medications and illicit drugs (eg, opioids) may cause respiratory depression in the newborn (Option 2). Current pregnancy diagnoses (eg, multiple gestation, placenta previa): Preparation for multiple newborns or high-risk maternal conditions requires more resuscitation equipment and staff (Option 3). Color of the amniotic fluid: Meconium-stained fluid may indicate fetal stress or hypoxia during labor, which could require newborn resuscitation after birth (Option 4). Expected due date (EDD) or estimated gestational age: A newborn at preterm gestation (<37 weeks gestation) is at risk for respiratory immaturity and may have respiratory distress after birth (Option 5). Educational objective:When a pregnant client arrives at the hospital and birth is imminent, the nurse should collect a brief history to elicit essential information relevant to potential newborn resuscitation. Identifying clients with recent medication or illicit drug use, multiple gestation or high-risk maternal conditions, meconium-stained amniotic fluid, or preterm gestational age is essential.

The nurse is verifying the medical history of a client who is admitted for a scheduled labor induction. Which client statement should prompt the nurse to request further evaluation for a primary cesarean birth from the health care provider? 1. "A vacuum was used to help deliver my last baby because the baby's heart rate was dropping." 2. "I have an atrial septal defect that has never given me any problems, and I plan to receive an epidural during labor." 3. "I lost my acyclovir prescription, and I've noticed lesions on my labia that are stinging and burning." 4. "I took enoxaparin during this pregnancy due to a history of blood clots, and my last dose was yesterday."

3. "I lost my acyclovir prescription, and I've noticed lesions on my labia that are stinging and burning." Genital herpes, an incurable sexually transmitted infection caused by herpes simplex virus (HSV), is characterized by painful, vesicular lesions that form ulcers that crust over. Clients with a history of genital herpes are prescribed antivirals (eg, acyclovir) around 36 weeks gestation to prevent outbreaks prior to labor. Clients with active genital herpes infections (eg, lesions) or prodromal symptoms (eg, pain, burning, tingling) require a cesarean birth to prevent transmission to the fetus (ie, neonatal HSV infection). The nurse should notify the health care provider of the client's symptoms and request further evaluation to help facilitate an appropriate plan of care (eg, cesarean birth) (Option 3). Educational objective: Clients with an active genital herpes infection or prodromal symptoms require further evaluation for a cesarean birth to prevent infection of the fetus. History of a vacuum-assisted birth, an asymptomatic atrial septal defect, and venous thrombus are not indications for cesarean birth.

The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client? 1. Apply tocodynamometer and evaluate current contraction pattern 2. Ask the client about the family's desire for speaking with a chaplain 3. Draw coagulation tests, fibrinogen, and complete blood count with platelets 4. Initiate oxytocin prescription to begin induction of labor

3. Draw coagulation tests, fibrinogen, and complete blood count with platelets Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for disseminated intravascular coagulation (DIC). Thromboplastin from the retained dead fetus activates the clotting cascade, followed by consumption of clotting factors and platelets that leads quickly to life-threatening external and internal bleeding. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (eg, petechiae, ecchymosis), and organ damage from blood clotting (eg, respiratory distress, renal failure). Baseline laboratory tests (eg, coagulation studies, platelets, fibrinogen) and physical assessment for signs of DIC are a priority for at-risk clients because clotting and bleeding are often sudden and life-threatening (Option 3). Educational objective: Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for developing disseminated intravascular coagulation (DIC). DIC can progress quickly; therefore, the nurse should prioritize assessment for any signs of DIC (eg, abnormal laboratory tests [coagulation studies, fibrinogen, platelets], signs of bleeding) before performing other interventions.

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider? 1. Clean the perineal area 2. Gently pull on the cord 3. Keep the infant warm 4. Massage the fundus

3. Keep the infant warm Precipitous birth occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is unable to arrive in time. Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or respiratory distress (Option 3). If the newborn is stable, the cord can be clamped and cut with sterile scissors after it has stopped pulsating or after the placenta has been expelled. Educational objective: Precipitous birth occurs when delivery takes place ≤3 hours after the onset of contractions. The nurse should prevent newborn cold stress by promptly drying and placing the newborn on the mother's abdomen for skin-to-skin contact.

A laboring client reports feeling the need to have a bowel movement and begins vomiting. The nurse notes that the client's legs are trembling. What cervical examination finding would the nurse most expect this client to have? 1. 2 cm dilated, 50% effaced, −2 station 2. 6 cm dilated, 70% effaced, −1 station 3. 7 cm dilated, 80% effaced, 0 station 4. 8 cm dilated, 100% effaced, +1 station

4. 8 cm dilated, 100% effaced, +1 station The end of the first stage of labor (8-10 cm dilation) is commonly referred to as the "transition phase" of labor. This period is often characterized by perineal/rectal pressure due to fetal descent, which the client may perceive as an urge to have a bowel movement. The maternal ischial spines are designated as the "0 station" landmark. During this period, descent of fetal station below the maternal ischial spines (ie, +1 station or greater) often results in nausea and vomiting and trembling or shivering (Option 4). Other maternal signs of the end of the first stage include increased pain, fear, irritability, anxiety, and self-doubt in the ability to birth. The client may require more assertive direction and emotional support during this period. Educational objective: Signs of the end of the first stage of labor ("transition phase") include perineal/rectal pressure, nausea and vomiting, trembling/shivering, increased pain, fear, irritability, and self-doubt. Laboring clients may require more assertive direction and additional emotional support during this period.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma

4. Vaginal hematoma A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. Educational objective:Vaginal hematomas are formed following trauma to the tissues of the perineum during vaginal delivery (eg, vacuum- or forceps-assisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal bleeding.