Maternal Child Nursing Care: Chapter 13-16 Uncomplicated Labor & Delivery

After monitoring the fetal heart activity, the nurse concludes that there is impaired fetal oxygenation. What had the nurse observed in the fetal monitor to come to this conclusion? Select all that apply. 1 Increase in the fetal heart rate (FHR) to over 160 beats/min 2 Early decelerations 3 Moderate variability 4 Late decelerations 5 Occasional variable decelerations

1, 4 Tachycardia (an increase in the FHR) is the early sign of fetal hypoxemia. Prolonged decelerations in FHR lasting for more than 2 minutes indicates the fetus is hypoxemic. Early decelerations, moderate variability, and occasional variable decelerations in the FHR are common observations during labor. These are normal findings and require no intervention.

On review of a fetal monitor tracing, the nurse notes that for several contractions the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: 1 describe the finding in the nurse's notes. 2 reposition the woman onto her side. 3 call the physician for instructions. 4 administer oxygen at 8 to 10 L/min with a tight face mask.

1 An early deceleration pattern from head compression is described. No action other than documentation of the finding is required because this is an expected reaction to compression of the fetal head as it passes through the cervix. Repositioning the woman onto her side would be implemented when non-reassuring or ominous changes are noted. Calling the physician would be implemented when non-reassuring or ominous changes are noted. Administering oxygen would be implemented when non-reassuring or ominous changes are noted.

What will the nurse mention about the effect of secondary powers during labor to the patient? 1 Contractions are expulsive in nature. 2 The intraabdominal pressure is decreased. 3 Contractions move downward in waves. 4 Contractions begin at pacemaker points.

1 As soon as the presenting part of the fetus touches the pelvic floor, the patient uses secondary powers or bearing-down efforts. This results in contractions that are expulsive in nature. The voluntary bearing-down efforts of the patient also result in increased intraabdominal pressure. Primary powers signal the beginning of labor with involuntary contractions that move downward over the uterus in waves. These contractions begin at pacemaker points in the thickened muscle layers of the upper uterine segment.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: 1 "Don't worry about it. You'll do fine." 2 "It's normal to be anxious about labor. Let's discuss what makes you afraid." 3 "Labor is scary to think about, but the actual experience isn't." 4 "You may have an epidural. You won't feel anything."

2 Discussing the woman's fears allows her to share her concerns with the nurse and is a therapeutic communication tool. Telling the woman not to worry negates her fears and is not therapeutic. Telling the woman that labor is not scary negates her fears and offers a false sense of security. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: 1 counterpressure against the sacrum. 2 pant-blow (breaths and puffs) breathing techniques. 3 effleurage. 4 biofeedback

1 Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

The nurse is caring for a patient in the first stage of labor. What maternal physiologic changes does the nurse expect? 1 Decrease in absorption of solid food 2 Increase in systolic and diastolic pressures 3 Increase in nausea and vomiting sensation 4 Increase in cardiac output by 30% to 50%

1 During the first stage of labor, gastrointestinal motility and absorption of solid foods are decreased, and stomach-emptying time is slowed down. Only systolic blood pressure increases during uterine contractions in the first stage of labor. Systolic and diastolic pressures increase during contractions in the second stage of labor and return to baseline levels between contractions. Nausea and vomiting sensations may occur during the transition from first stage to second stage of labor. In the first stage of labor, the cardiac output increases by 10% to 15%. Cardiac output increases by 30% to 50% only at the end of the first stage of labor and not in the first stage.

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's most appropriate analgesic for pain control is: 1 fentanyl (Sublimaze). 2 promethazine (Phenergan). 3 butorphanol tartrate (Stadol). 4 nalbuphine (Nubain)

1 Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.

Fetal well-being during labor is assessed by: 1 the response of the fetal heart rate (FHR) to uterine contractions (UCs). 2 maternal pain control. 3 accelerations in the FHR. 4 an FHR greater than 110 beats/min

1 Fetal well-being during labor is measured by the response of the FHR to UCs . In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

What kind of anesthesia does the nurse expect the primary health care provider to prescribe to a patient who is to have an emergency cesarean birth due to fetal distress? 1 General anesthesia 2 Pudendal nerve block 3 Nitrous oxide with oxygen 4 Local infiltration anesthesia

1 General anesthesia may be necessary if indications necessitate rapid birth (vaginal or emergent cesarean), when there is a pressing need for time and/or primary health care providers to perform a block. Pudendal nerve block is administered late in the second stage of labor. It may be required if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Nitrous oxide mixed with oxygen can be inhaled in 50% or less concentration to provide analgesia during the first and second stages of labor. Local infiltration anesthesia may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia.

After reviewing the laboratory reports of a pregnant patient at term, the primary health care provider (PHP) advised the nurse to administer intravenous (I.V.) fluids to the patient. What is the reason for giving such advice? 1 Dehydration 2 Hypertension 3 Maternal hyperglycemic 4 Preterm labor

1 I.V. fluids are administered to increase the amount of fluids and restore the electrolyte balance. As the patient is dehydrated, the PHP advises the nurse to administer I.V. fluids. Administration of I.V. fluids as a medical treatment for the prevention of preterm labor is not indicated unless medical management involves use of therapeutic protocols such as magnesium sulfate. As the patient is at term, preterm labor would not be a factor. Administering fluids may increase the venous pressure, thereby enhancing the blood pressure. Therefore I.V. fluids must not be administered if the patient has hypertension. Other prospective medical management should be initiated if maternal hypertension is noted. I.V. fluids should not be administered to hyperglycemic patients, but rather other prospective medical management should be initiated if maternal hyperglycemia is noted and deemed to be significant.

The nurse is caring for a patient who is in the third trimester of pregnancy. The patient reports pain in the pelvic joints. What does the nurse recognize as the cause of the pain? 1 There is relaxation of the pelvic joints. 2 There is decreased mobility of the ligaments. 3 The joint of the symphysis pubis is narrowing. 4 The pelvis may not support vaginal birth.

1 In the third trimester of pregnancy, the pelvic joints relax, leading to pain. There is increased mobility of the pelvic joints and ligaments as a result of hormonal influences. Widening of the joint of the symphysis pubis and the resulting instability may cause pain in any or all of the pelvic joints. Pain in the pelvic joints does not indicate that the pelvis may not support vaginal birth. A heart shaped android pelvis may not support spontaneous vaginal birth.

The nurse is caring for a non-English-speaking pregnant patient. What nursing interventions would help explain the procedure of vaginal examination to the patient? 1 Call a service for an interpreter. 2 Try to communicate nonverbally. 3 Limit the use of medical terminologies. 4 Ask for the assistance of the hospital staff

1 It is important that the nurse explain the procedure to the patient. Because the patient does not speak English, it is advisable to call an interpreter. This helps the patient understand the test procedures without any confusion. Nonverbal communication is not useful in this case, because it may cause the patient to become confused. Explaining the medical examination procedure may include complex terms and words. Limiting those words may not help clarify to the patient who does not speak English. Finally, the patient may not feel comfortable in the presence of additional hospital staff.

The nurse is caring for a patient who is administered local perineal infiltration anesthesia. In what situation does the nurse expect the use of local perineal infiltration anesthesia? When a(n): 1 Episiotomy is required. 2 Forceps birth is expected. 3 Cesarean birth is expected. 4 Vacuum extractor is to be used.

1 Local perineal infiltration anesthesia may be used when an episiotomy is to be performed. It may also be used when lacerations must be sutured after birth in a patient who does not have regional anesthesia. Pudendal nerve block is administered late in the second stage of labor if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Low spinal anesthesia (block) may be used for cesarean birth.

Nurses should be aware of the difference experience can make in labor pain, such as: 1 sensory pain for nulliparous women often is greater than for multiparous women during early labor. 2 affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. 3 women with a history of substance abuse experience more pain during labor. 4 multiparous women have more fatigue from labor and therefore experience more pain.

1 Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? 1 The fetal presenting part is 1 cm above the ischial spines. 2 Effacement is 4 cm from completion. 3 Dilation is 50% completed. 4 The fetus has achieved passage through the ischial spines.

1 Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

The primary health care provider has administered terbutaline (Brethine) to a pregnant patient to postpone preterm labor. What changes would the nurse observe in the fetal heart monitor after this drug was administered? 1 Increase in fetal heart rate 2 Decrease in fetal heart rate 3 Accelerations in heart rate 4 Decelerations in heart rate

1 Terbutaline (Brethine) is usually prescribed to postpone labor, because the drug reduces the frequency of uterine contractions. Terbutaline (Brethine) can also increase the fetal heart rate (FHR). Terbutaline (Brethine) does not decrease the heart rate, nor does it cause any accelerations or decelerations in the FHR. Heart block or viral infections can decrease the FHR and may result in bradycardia. There may be accelerations in the FHR during a vaginal examination. A parasympathetic response may cause decelerations in heart rate. Terbutaline is a sympathomimetic drug and thus does not cause decelerations in FHR.

The nurse palpates the fontanels and sutures to determine the fetal presentation. What is the feature of the anterior fontanel? 1 It is diamond shaped in appearance. 2 It measures about 1 cm by 2 cm. 3 It closes after 6 to 8 weeks of birth. 4 It lies near the occipital bone.

1 The anterior fontanel is diamond shaped and measures about 3 cm by 2 cm. It closes by 18 months after birth. It lies at the junction of the sagittal, coronal, and frontal sutures. The posterior fontanel is triangular in shape and measures about 1 cm by 2 cm. It closes 6 to 8 weeks after birth. It lies at the junction of the sutures of the two parietal bones and the occipital bone.

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: 1 the examiner's hand should be placed over the fundus before, during, and after contractions. 2 the frequency and duration of contractions are measured in seconds for consistency. 3 contraction intensity is given a judgment number of 1 to 7 by the nurse and patient together. 4 the resting tone between contractions is described as either placid or turbulent.

1 The assessment includes palpation; duration, frequency, intensity, and resting tone. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

When the nurse observes this fetal heart pattern, the most important nursing action is to: 1 document the finding. 2 position mother on left side. 3 apply 10 L of oxygen via face mask. 4 notify the health care provider

1 The fetal heart strip shows an early deceleration indicating expected head compression during contractions. Documenting this finding is appropriate. Positioning the woman on the left aside, applying oxygen via a face mask, and notifying the health care provider are correct actions for a late deceleration.

The nurse is assessing a patient in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. Which phase of labor is the patient in? 1 Latent phase 2 Active phase 3 Transition phase 4 Descent phase

1 The patient is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase, or active pushing phase, occurs in the second stage of labor. In this phase, the patient has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.

The nurse is caring for a pregnant patient. What interventions should the nurse follow to ensure proper hygiene in the patient? 1 Clean the perineum of the patient frequently. 2 Clean the patient's teeth with a warm wet cloth. 3 Offer a warm washcloth to the patient for a face wash. 4 Allow cool water to flow on the patient's back for 5 minutes.

1 The patient's perineum should be cleaned frequently to prevent the risk for infection. This helps maintain proper hygiene and provides comfort to the patient. The nurse can clean the patient's teeth with an ice-cold wet washcloth, which helps prevent a feeling of thirst and dryness of the mouth. Using a warm cloth may not be helpful. The patient is offered a cool cloth for wiping her face, which helps prevent diaphoresis. Warm water should be poured on the patient's back to provide relaxation and accelerate labor. Using a warm washcloth for a face wash and placing cool water on the patient's back will not help in providing comfort.

What response does the nurse expect when a laboring patient is administered analgesic medication early in labor? 1 Painless intrauterine contractions 2 Increased frequency of contractions 3 Increased intensity of contractions 4 Rapid descent of the fetus

1 Uterine contractions are usually independent of external forces. Laboring patients who are administered analgesic medication have normal but painless uterine contractions. However, uterine contractions may decrease in frequency and intensity temporarily, if narcotic analgesic medication is administered early in labor. The first and second stages of labor are lengthened, and the rate of fetal descent slows down.

Nurses can advise their patients that which of these signs precede labor? Select all that apply. 1 A return of urinary frequency as a result of increased bladder pressure 2 Persistent low backache from relaxed pelvic joints 3 Stronger and more frequent uterine (Braxton Hicks) contractions 4 A decline in energy, as the body stores up for labor 5 Uterus sinks downward and forward in first-time pregnancies

1, 2, 3 After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor , women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term.

For the labor nurse, care of the expectant mother begins with which situations? Select all that apply. 1 The onset of progressive, regular contractions 2 The bloody, or pink, show 3 The spontaneous rupture of membranes 4 Formulation of the woman's plan of care for labor 5 Moderately painful contractions

1, 2, 3 Labor care begins with the onset of progressive, regular contractions. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when the blood-tinged mucoid vaginal discharge appears. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when amniotic fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Pain is subjective. The onset of progressive, regular contractions signals the beginning of labor, not the intensity of the pain.

What interventions does the nurse perform for a laboring patient with hypotension and fetal bradycardia? Select all that apply. 1 Notify the primary health care provider or anesthesiologist. 2 Monitor the fetal heart rate (FHR) every 5 minutes. 3 Monitor maternal blood pressure every 10 minutes. 4 Administer oxygen using a non rebreather facemask. 5 Position the patient in Sims' or modified Sims' position.

1, 2, 4 The nurse must immediately notify the primary health care provider, anesthesiologist, or nurse anesthetist. The nurse must administer oxygen by nonrebreather facemask at 10 to 12 L/min or as per health care facility's protocol. The FHR must be monitored every 5 minutes. The patient must be turned to lateral position or a pillow or wedge must be placed under a hip to displace the uterus. Sims' or modified Sims' position may be used when spinal anesthesia is administered. Maternal blood pressure must be monitored every 5 minutes.

The nurse is caring for a patient who had a normal vaginal birth. The patient is concerned about the shape of the infant's head. What does the nurse tell the patient? Select all that apply. 1 The bones of the skull continue to grow after birth. 2 The shape of the head undergoes molding during labor. 3 The head assumes its normal shape within a month. 4 The skull bones of an infant are generally firmly united. 5 The sutures and fontanels make the skull flexible

1, 2, 5 The bones of the skull continue to grow for some time after birth to accommodate the infant's brain. During labor, the shape of the head gets molded as the bones undergo a slight overlapping. The sutures and fontanels are membranous structures that unite the skull bones and make the skull flexible. Molding can be extensive, but the heads of most newborns assume their normal shape within 3 days after birth. The skull bones are held together by sutures and fontanels and are not firmly united in an infant.

The nurse finds that the pregnant patient has impaired urinary elimination. Which interventions should be performed by the nurse to relieve the patient's problem? Select all that apply. 1 Encourage the patient to urinate every 2 hours. 2 Catheterize the patient immediately for voiding. 3 Palpate patient's bladder superior to symphysis. 4 Ask the patient to place the hand in running water. 5 Provide effleurage massage to the patient frequently.

1, 3, 4 Impaired urinary elimination occurs as a result of sensory impairment caused by the labor process. Therefore the nurse has to perform interventions that help in emptying the patient's bladder every 2 hours. The nurse should encourage the patient to void every 2 hours to avoid bladder distention. The nurse can use running water to stimulate voiding by asking the patient to keep her hands in the running water. The nurse should palpate the patient's bladder on a frequent basis to detect the inability to void. The nurse should not catheterize the patient immediately for voiding, because it may result in trauma to the bladder. Effleurage helps in reducing pain but does not help stimulate voiding in the patient.

The nurse teaches the patient nonpharmacologic pain management methods during a prenatal class. Which methods require practice for best results? Select all that apply. 1 Biofeedback 2 Massage and touch 3 Patterned breathing 4 Controlled relaxation 5 Slow-paced breathing

1, 3, 4 Patterned breathing, controlled relaxation, and biofeedback techniques must be practiced to obtain best results. Patterned breathing and controlled relaxations help to manage pain during labor. Biofeedback is effective when the patient is able to focus and control body responses during labor. The nurse assisting the laboring patient can use methods such as massage and touch and slow-paced breathing successfully without the patient having any prior knowledge about it.

Under which circumstances should a vaginal examination be performed by the nurse? Select all that apply. 1 An admission to the hospital at the start of labor 2 When accelerations of the fetal heart rate (FHR) are noted 3 On maternal perception of perineal pressure or the urge to bear down 4 When membranes rupture 5 When bright, red bleeding is observed

1, 3, 4 Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM), a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. An accelerated FHR is a positive sign; variable decelerations, however, merit a vaginal examination. Examinations are never done by the nurse if vaginal bleeding is present because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

The nurse assesses a pregnant patient and reports to the primary health care provider (PHP) that the patient is in the second stage of labor. Which of the patient's signs enabled the nurse to give such a report to the PHP? Select all that apply. 1 Urge to defecate 2 Cheeks appear to be flushing 3 Cervical dilation of 10 cm 4 Brownish discharge of mucus from the vagina 5 Premature urge to bear down

1, 3, 5 After an assessment, the nurse reports to the PHP that a pregnant patient is in the second stage of labor because the patient has a cervical dilation of 10 cm (fully dilated). The patient has a premature urge to bear down and an urge to defecate. The patient may have flushed cheeks in the active phase of first stage of labor, but it is not a sign of second stage of labor. Brownish discharge of mucus is a sign of latent phase of first stage of labor, but does not appear in the second stage of labor.

A patient has been admitted to the labor room. What are the measures to be taken by the nurse to support the partner of the patient? Select all that apply. 1 Offer snacks and fluids to the partner as required. 2 Do not discuss the psychological change in the patient. 3 Demonstrate the performance of the comfort measures. 4 Guide the partner to make decisions about his involvement. 5 Relieve the person occasionally from the job of supporting the patient.

1, 3, 5 Any comfort measures useful for the patient should be demonstrated to the patient's partner. The patient's partner may be reminded to take food. The nurse can also offer snacks and fluids to the partner. The nurse can offer to relieve him of the duty of supporting and encouraging the patient in order to get proper rest. The decision regarding the involvement of the partner in the process of labor should be left to the couple. The nurse should respect their decision. The nurse should tell the partner about the changes that may take place in the patient's behavior during labor and childbirth.

What are the common signs that are observed in the days preceding labor? Select all that apply. 1 Persistent low backache 2 Sudden increase in lethargy 3 Blood-tinged cervical mucus 4 Increase in weight up to 1.5 kg 5 Profuse vaginal mucus

1, 3, 5 Common signs that precede labor include persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Brownish or blood-tinged cervical mucus may be passed. The vaginal mucus becomes more profuse in response to the extreme congestion of the vaginal mucous membranes. In the days preceding labor, women generally have a sudden surge of energy. They also experience a loss of 0.5 to 1.5 kg in weight. This is caused by water loss resulting from electrolyte shifts that in turn are produced by changes in estrogen and progesterone levels.

What are the factors that speed up the dilation of the cervix? Select all that apply. 1 Strong uterine contractions 2 Scarring of the cervix 3 Pressure by amniotic fluid 4 Prior infection of the cervix 5 Force by fetal presenting part

1, 3, 5 Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are, in turn, caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.

What interventions does the nurse perform to provide emotional support to a patient in labor? Select all that apply. 1 Compliment patient efforts during labor. 2 Avoid offering food during labor. 3 Use a calm, confident approach. 4 Discourage activities that distract. 5 Involve the patient in care decisions.

1, 3, 5 The nurse must offer emotional support by complimenting the patient and offering positive reinforcement for efforts during labor. The patient must be involved in decision making regarding own care. The nurse must use a calm and confident approach when assisting the patient during labor. The nurse may offer food and nourishment, if allowed by the primary health care provider. The nurse must encourage participation in distracting activities and nonpharmacologic measures for comfort.

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Select all that apply. 1 Imagine breathing in light and energy. 2 Maintain clenched fists to drive out pain. 3 Engage in dance or rhythmic movements. 4 Imagine walking through a restful garden. 5 Envisage breathing out worries and tension.

1, 4, 5 Imagery and visualization are useful techniques in preparation for birth and are often used in combination with relaxation. Imagery involves techniques, such as breathing in light and energy, imagining a walk through a restful garden, or envisaging breathing out worries and tension. Relaxation or reduction of body tension is a technique that involves rhythmic motion that stimulates the mechanoreceptors of the brain. The nurse must recognize the signs of tension, such as clenching of fists when in pain by the laboring patient.

The nurse teaches acupressure methods for pain relief during labor to a couple in the prenatal clinic. What does the nurse teach about acupressure? Select all that apply. 1 Blood circulation is enhanced. 2 Flow of qi (energy) is restored. 3 Lubricants are used over the area. 4 Pressure is applied with the fingers. 5 Pressure is applied with contractions.

1, 4, 5 Pressure is usually applied with the heel of the hand, fist, or pads of the thumbs and fingers. Pressure is applied with contractions initially and then continuously as labor progresses to the transition phase at the end of the first stage of labor. Acupressure is said to promote the circulation of the blood, the harmony of yin and yang, and the secretion of neurotransmitters. Thus acupressure maintains normal body functions and enhances well-being. Acupressure is applied over the skin without using lubricants. In acupuncture, the flow of qi (energy) is restored.

The nurse acts as an advocate for the patient during an informed consent. What care must the nurse take while obtaining an informed consent? Select all that apply. 1 Check for the patient's signature. 2 Ensure that the consent is in English. 3 Obtain a family member's signature. 4 Check for the date on the consent form. 5 Check the anesthetic care provider's signature.

1, 4, 5 The nurse must ensure that the consent form has the correct date. The nurse must ensure that the patient has not been compelled to consent for the procedure. The form must carry the signature of the anesthetic care provider, certifying that the patient has received and expresses understanding of the explanation. The consent form must be written or explained in the patient's primary language. The nurse need not obtain a family member's signature on the document. The patient's signature is important.

The nurse is teaching a patient, who is pregnant for the first time, about the signals that indicate the beginning of labor. Which sign will the nurse mention as a signal for the beginning of labor? 1 Involuntary contractions 2 Pain in the pelvic joints 3 100% effacement of the cervix 4 Full dilation of the cervix

1. Involuntary contractions

What care must the nurse take when implementing aromatherapy for a patient in labor? 1 Apply oil to the skin and massage. 2 Ask the patient to choose the scents. 3 Apply a few drops of oil to the hair. 4 Allow inhalation of warm oil vapors

2 Certain scents can evoke pleasant memories and feelings of love and security. So, it is helpful if the patient is allowed to choose the scents. The oils must never be applied in full strength directly on to the skin. Most oils should be diluted in a vegetable oil base before use. Inhaling vapors from the oil can lead to unpleasant side effects like nausea or headache. Drops of essential oils can be put on a pillow or on a woman's brow or palms or used as an ingredient in creating massage oil. It is not applied to the hair.

What are the factors that enable the baby to initiate respiration immediately after birth? 1 Fetal respiratory movements increase during labor. 2 Fetal lung fluid is cleared from the air passage. 3 Arterial carbon dioxide pressure is decreased. 4 Arterial pH and bicarbonate level is increased.

2 Fetal lung fluid is cleared from the air passage as the infant passes through the birth canal during labor and vaginal birth. There is a decrease in fetal respiratory movements during labor. Arterial carbon dioxide pressure (Pco2) increases. There is a decrease in arterial pH and bicarbonate levels.

What does the nurse teach the patient about the benefits of breathing techniques in the second stage of labor? 1 Does not interfere with fetal descent 2 Causes increase in abdominal pressure 3 Reduces discomfort during contractions 4 Increases the size of the abdominal cavity

2 In the second stage of labor breathing technique is used to increase abdominal pressure and expel the fetus. In the first stage of labor, breathing helps to promote the relaxation of the abdominal muscles, thereby increasing the size of the abdominal cavity. This lessens the discomfort during contraction caused by the friction between the abdominal wall and the uterus. It also relaxes the muscles of the genital area and does not interfere with fetal descent.

Nurses can help their patients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? 1 Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours 2 Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours 3 Lull: no contractions; dilation stable; duration of 20 to 60 minutes 4 Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

2 The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

The nurse is caring for a pregnant patient during labor. What should the nurse do immediately after the child's birth? 1 Ask the mother to hold the infant. 2 Dry the infant and place in warm blanket. 3 Record the Apgar scores after 30 minutes. 4 Cut the umbilical cord 3.5 cm above the clamp.

2 The infant should be dried to prevent cold stress due to rapid loss of heat and then covered with a warm blanket. The Apgar score is to be recorded at 1 and 5 minutes after the birth of the infant. Recording it after 30 minutes may lead to failure in assessing the fetal signs. The cord should be cut at 2.5 cm above the placement of the clamp. A newborn may be very slippery to hold, and the mother may not be able to hold the baby due to fatigue. The infant can be given to the mother only after complete drying.

The diagnostic test reports of a pregnant patient reveal a baseline fetal heart rate of 175 beats/min. What does this finding indicate to the nurse? 1 Presence of fetal ischemia 2 Fetal tachycardia 3 Fetal bradycardia 4 Hypotension in the fetus

2 The normal baseline fetal heart rate ranges from 110 to 160 beats/min. If the fetal heart rate is more than 160 beats/min, then tachycardia in the fetus is indicated. Ischemia is a condition in which there is a reduced blood supply to the fetal tissues. Baseline heart rate below 110 beats/min indicates bradycardia in fetus. Hypotension indicates a blood pressure level below 120/80 mm Hg, which is a life-threatening condition for the fetus.

After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient? 1 Help the patient to lie in supine position on the bed. 2 Encourage the patient to sit in hands-and-knees position. 3 Place a pillow under the patient's hip when lying in supine position. 4 Ask the patient to lie in lateral position on the opposite side of the fetal spine.

2 The nurse should place the patient in a position that helps the rotation of the fetal occiput from a posterior to an anterior position. Therefore the nurse should encourage the patient to sit in hands-and-knees position, as it increases the pelvic diameter, allowing the head to rotate toward anterior position. The patient should not lie in supine position, as it may cause postural hypotension. Placing a pillow under the patient's hip when lying in supine position helps prevent supine hypotensive syndrome, but does not help in delivering the baby. The nurse should not ask the patient to lie in lateral position on the opposite side of the fetal spine, as it increases counter pressure on the back. Instead, lying in lateral position on the same side of the fetal spine will help the fetus rotate toward the posterior, as the gravity pulls the fetal back forward.

The nurse is assessing a pregnant patient in the last week of gestation. The nurse observes that the patient has flushed cheeks, uterine contractions (UCs) of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. What stage of labor should the nurse infer that the patient is in based on these observations? 1 Latent phase 2 Active phase 3 Transition phase 4 Active pushing phase

2 The patient has flushed cheeks, UCs of 65 seconds with a frequency of 4 minutes, and pink to bloody mucus. These symptoms are observed during the active phase of labor. The symptoms of the patient do not correlate with the latent, transition, or active pushing phases (second stage) of labor. In the latent phase of labor, the UCs are 30 to 45 seconds with a frequency of 5 to 30 minutes, and the mucus is pale pink. In the transition phase, the UCs are 45 to 90 seconds with a frequency of 2 to 3 minutes, and the mucus appears bloody. In the active pushing phase of the second stage of labor, the UCs are 90 seconds with a frequency of 2 to 2.5 minutes.

A patient in labor exhibits flushed cheeks. The nurse records the uterine contractions in the patient as being 3 to 5 minutes apart and lasting for about 1 minute. What nursing intervention is most effective to assess the patient's status during this phase of labor? 1 Check blood pressure every 2 hours. 2 Note patient's appearance and mood every 15 minutes. 3 Assess the patient's temperature every 2 hours until membranes rupture.

2 The patient is experiencing uterine contractions that are 3 to 5 minutes apart and last for about 60 seconds (1 minute). The patient also exhibits flushed cheeks. These findings indicate that the patient is in the active phase of the first stage of labor. The nursing assessment in the active stage of labor is to check the patient's appearance and mood every 15 minutes, or 4 times in an hour. The patient's mood and energy levels fluctuate, and therefore the nurse should constantly assess them to ensure effective patient care. The patient's blood pressure should be assessed every 30 minutes. The nurse should assess the patient's body temperature every 4 hours until membrane rupture and thereafter every 2 hours.

The nurse restricts the visitors of a pregnant patient and gives a specific time for the patient to rest and sleep after the labor. What maternal patient experience could be the probable reason for this nursing action? 1 Severe pain during labor 2 Severe fatigue during labor 3 Ineffective birth process 4 Problem of irregular urination

2 The patient may have severe fatigue after labor due to depletion of energy. In order to restore the energy levels, the nurse gives a specific time for the patient to rest and sleep by restricting the visitors. Severe pain, inefficiency in the birth process, and a problem of irregular urination are not the reason for the nurse to limit visitors. The nurse would administer analgesics or anesthesia on an order if the patient experienced acute pain. The nurse would provide comfort measures if the patient was ineffective in the birth process. The nurse would palpate the patient's bladder if irregular urination were a concern.

The nurse knows that the second stage of labor has begun when: 1 the amniotic membranes rupture. 2 full cervical dilation has occurred. 3 the woman experiences an urge to bear down. 4 the presenting part is below the ischial spines.

2 The second stage of labor begins with full cervical dilation. During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation.

While monitoring the fetal heart rate (FHR), the nurse instructs the patient to change positions and lie in the knee-to-chest position. What is the reason for the nurse to give this instruction to the patient? 1 Late decelerations in the FHR 2 Variable decelerations in the FHR 3 Early decelerations in the FHR 4 Prolonged decelerations in the FHR

2 Variable decelerations in the FHR are usually caused by umbilical cord compression. The knee-to-chest position is useful for relieving cord compression, and thus the nurse should ask the patient to move into this position. Prolonged decelerations in the FHR are not affected by the mother's position. If the nurse finds late decelerations in the FHR, the nurse should ask the mother to lie in the lateral position. Early decelerations in the FHR are a normal finding, and no nursing intervention is required.

The nurse is briefing a patient who is pregnant for the first time about lightening. Which statement should the nurse mention to describe lightening to the patient? 1 It occurs when true labor is in progress. 2 It allows the patient to breathe more easily. 3 It decreases the pressure on the bladder. 4 It leads to decreased urinary frequency.

2 When the fetal head descends into the true pelvis during lightening, the patient will feel less congested and can breathe more easily. In a first-time pregnancy, lightening occurs about 2 weeks before term. In a multiparous pregnancy, lightening may not take place until after the uterine contractions are established and the true labor is in progress. This shift increases the pressure on the bladder and causes a return of urinary frequency.

During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine. 2 1 cm above the ischial spine. 3 at the level of the ischial spine. 4 1 cm below the ischial spine.

2 When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

After observing the electronic fetal monitor, a primary health care provider asks the nurse to conduct an electrocardiogram (ECG) of the fetus. What should the nurse assess before obtaining an ECG of the fetus? Select all that apply. 1 Fetal lactate levels 2 Placental membranes 3 Cervical dilation 4 Umbilical cord compression 5 Frequency of uterine contractions

2, 3 When performing the ECG of the fetus, the nurse should insert the electrode into the cervix to reach the fetus. Therefore the nurse should check if the cervix is dilated up to 3 cm and if the membranes are ruptured. This allows the nurse to reach the fetus's position. Lactate levels do not affect the ECG testing and thus need not be checked before the test. Umbilical cord compression or decreased frequency of UCs is not the required conditions for performing an ECG on the fetus.

Which patients are more susceptible to soft-tissue damage with vaginal deliveries? Select all that apply. 1 Multiparous patients 2 Nulliparous patients 3 Patients needing forceps delivery 4 Patients with fetal vertex presentation 5 Patients with fetal breech presentation

2, 3, 5 A nulliparous patient has rigid perineal tissue making it susceptible to injury. Fetal breech presentation exerts undue pressure on the tissues, increasing the risk of injuries. Forceps delivery also increases the risk of injury due to undue stretch of the perineum. Multiparous patients have stretchable perineal tissues, which are less likely to get injured during childbirth. Fetal vertex presentation causes the least amount of tissue damage.

The nurse is assisting a pregnant patient in labor. What instructions should the nurse give to the patient to promote comfort? Select all that apply. 1 "You should cough frequently." 2 "Breathe with your mouth open." 3 "Lie down in the lateral position." 4 "Lie in the supine position in bed." 5 "Lie in the semi-Fowler position."

2, 3, 5 The nurse helps the pregnant patient during labor. This includes teaching the patient relaxation techniques. The nurse teaches the patient to keep the mouth open during exhalation to allow air to easily leave the lungs. Placing the patient in a semi-Fowler or lateral position is helpful during labor. Therefore the nurse should instruct the patient to maintain a lateral or semi-Fowler position with a lateral tilt. Asking the patient to cough frequently would increase intraabdominal pressure of the patient and would make the patient uncomfortable. Having the patient lie down in a supine position during labor may cause orthostatic hypotension. Therefore the nurse should instruct the patient to lie down in a position other than supine.

While caring for a multiparous patient in the second stage of labor, the patient reports the urge to defecate. What is the best nursing intervention? 1 Provide a bedpan to the patient to defecate. 2 Place an enema in the rectum of the patient. 3 Assess cervical dilation and station of the patient. 4 Use running water to stimulate defection for the patient.

3 A multiparous patient feels an urge to defecate in the second stage of labor due to rectal pressure by the deeply descending presenting part in the pelvis. Rectal pressure may occur even in the absence of stool in the anorectal area. This often means that the patient is about to give birth to the child. Therefore the nurse has to perform vaginal examination of the patient to assess cervical dilation and station. The patient does not really defecate, so providing a bedpan is not necessary. Placing an enema in the rectum of the patient is not a suitable intervention, as it is done to increase peristalsis. Running water is used to stimulate voiding for the patient if there is a risk of urinary elimination. However, it is unrelated to the patient's urge of defecation.

Which device can be used as a noninvasive way to assess the fetal heart rate (FHR) in a patient whose membranes are not ruptured? 1 Tocotransducer 2 Spiral electrode 3 Ultrasound transducer 4 Intrauterine pressure catheter (IUPC)

3 An ultrasound transducer is used to assess the FHR by an external mode of electronic fetal monitoring. It does not require membrane rupture and cervical dilation. A tocotransducer can be used to assess the uterine activity (UA) in a pregnant patient whose cervix is not sufficiently dilated, but it does not assess the FHR. Spiral electrode is used as an internal mode of electronic fetal monitoring to assess the FHR. It can be used only when the membranes are ruptured and the cervix is dilated during the intrapartum period. IUPC is used to assess uterine activity in internal mode. It can be used only when the membranes are ruptured and the cervix is dilated during the intrapartum period.

The nurse instructs a pregnant patient to breathe through the mouth and keep it open while pushing during labor. What is the rationale for this nursing intervention? 1 To avoid nasal congestion in the patient 2 To decrease the efforts required for pushing 3 To facilitate increased oxygen to the fetus 4 To avoid deceleration in the fetal heart rate

3 During labor, the nurse asks the patient to breathe through the mouth to keep the mouth open to increase both maternal and fetal oxygenation. Nasal congestion is not a complication associated with labor. Opening of the mouth does not increase the pushing capability. Early decelerations are observed by pushing which does not require any intervention.

The nurse is caring for a patient who is using fentanyl citrate (Sublimaze) through patient-controlled analgesia (PCA) while in labor. What effects of fentanyl citrate does the nurse expect? 1 Provides long duration of action 2 Requires only a single dose 3 Provides quick relief to pain 4 Causes sedation and nausea

3 Fentanyl citrate (Sublimaze) is a potent short-acting opioid agonist analgesic. Therefore it provides quick pain relief. It rapidly crosses the placenta, so it is present in the fetal blood within 1 minute after intravenous maternal administration. It is a short-acting drug, so the patient will require more frequent dosing. It is often administered as a patient controlled analgesic. It has fewer neonatal effects as compared to meperidine, and causes less maternal sedation and nausea.

The nurse assesses the fetal heart rate (FHR) of a pregnant patient and finds minimal FHR variability. The nurse reassesses the patient 30 minutes later and finds moderate variability. What should the nurse infer? 1 No acceleration 2 Late deceleration 3 Baseline heart rate is 150 beats/min 4 Baseline heart rate is 180 beats/min

3 If the nurse notes minimal FHR variability, the nurse should reassess the heart rate to determine a pattern. If in 30 minutes the nurse notices moderate variability, the fetus may be in a sleep state. The nurse would further confirm after half an hour and report it as moderate variability, where the heart rate baseline is confirmed as normal (110-160 beats/min). Heart rate variability is a characteristic of the baseline FHR and does not include accelerations or decelerations of the FHR. A fetal baseline heart rate of 180 beats/min is considered severe variability.

The nurse is assessing a pregnant patient during labor and reports the normal duration of the contraction period as 2 minutes, 15 seconds in a span of 10 minutes. What would be the number of contractions observed in this span of 10 minutes? Record your answer using a whole number._______

3 In a pregnant patient the normal range of uterine contractions (UCs) during labor are noted to be 2 to 5 in every 10 minutes. Each one contraction lasts from 45 to 80 seconds. Therefore, when the nurse reports the contraction period as 2 minutes, 15 seconds (135 seconds) in 10 minutes of time, the nurse should have observed 135 ÷ 45 = 3 contractions.

The primary health care provider has administered general anesthesia to a patient who is scheduled for an elective cesarean section. What changes should the nurse observe in the fetal heart rate (FHR) after the administration of general anesthesia? 1 Decrease 2 Increase 3 Minimal variability 4 Moderate variability

3 It is necessary to monitor the FHR in the pregnant patient who is given general anesthesia. General anesthesia usually causes minimal variability or no change in the FHR. Tachycardia is caused by fetal hypoxemia, whereas bradycardia is caused from a structural defect in the fetal heart. Moderate variability in the FHR indicates normal fetal activity.

The nurse is caring for a nulliparous patient in labor. How is the experience for a nulliparous patient different from that of a multiparous patient? The patient experiences: 1 Less sensory pain during early labor. 2 Greater sensory pain in the second stage of labor. 3 Greater fatigue due to longer duration of labor. 4 Greater affective pain in the second stage of labor.

3 Parity influences the perception of labor pain. The nulliparous patient often has longer labor and therefore, greater fatigue. Sensory pain for nulliparous women is often greater than that for multiparous women during early labor, because their reproductive tract structures are less supple. Affective pain in the nulliparous patient is greater in the first stage as compared to a multiparous patient. It decreases for both patients during the second stage of labor. During the second stage of labor, the multiparous patient may experience greater sensory pain than the nulliparous patient. This is because tissues of the multiparous patient are more supple and increase the speed of fetal descent, thereby intensifying the pain.

The nurse is examining a newly admitted patient who is 39 weeks pregnant and notes that the patient is in the transition phase of labor. Which symptoms does the nurse note to reach this conclusion? 1 No evidence of uterine contractions (UCs) 2 Mild uterine contractions (UCs) 3 Strong uterine contractions (UCs) 4 Moderate uterine contractions (UCs)

3 Regular and strong UCs may occur in the transition phase of labor. Absence of uterine contractions means that the labor has not started. Mild UCs can be observed during early labor. Mild to moderate UCs can be observed during the latent and active phases of labor.

What intervention does the nurse perform to provide a relaxed environment for labor? 1 Stand at the bedside. 2 Encourage rapid birth. 3 Control sensory stimuli. 4 Demonstrate excitement

3 The nurse must assist the patient by providing a quiet and relaxed environment. A relaxed environment for labor is created by controlling sensory stimuli, such as light, noise, and temperature, as per the patient's preferences. The nurse must provide reassurance and comfort by sitting rather than standing at the bedside whenever possible. The nurse must not encourage or hurry the patient for rapid birth. The nurse must maintain a calm and unhurried attitude when caring for the patient.

During the second phase of labor the patient initiates pattern-paced breathing. What adverse symptoms must the nurse watch for when the patient initiates this method? 1 Pallor 2 Nausea 3 Dizziness 4 Diaphoresis

3 The nurse must watch for symptoms of hyperventilation and resulting respiratory alkalosis. Symptoms of respiratory alkalosis during pattern-paced breathing include dizziness, light-headedness, tingling of fingers, or circumoral numbness. Pallor, nausea, and diaphoresis are generally observed in the active and transition phases of the first stage of labor. They are physiologic effects of pain.

During the prenatal assessment of a patient, the nurse teaches the patient about nonpharmacologic pain management. What does the nurse tell the patient about this method? 1 It is technical and expensive. 2 It requires intensive training. 3 It provides the patient with a sense of control. 4 It is used only in stage I of labor.

3 The patient makes choices about the nonpharmacologic pain management methods that are best suited. This provides the patient with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the patient may obtain best results from the practice. It can be used throughout labor.

In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth

3 The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by: 1 narcotics. 2 barbiturates. 3 methamphetamines. 4 tranquilizers.

3 The use of illicit drugs (such as cocaine or methamphetamines) might cause increased variability . Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates may also result in a significant decrease in variability as these are known to cross the placental barrier. Tranquilizer use is a possible cause of decreased variability in the fetal heart rate.

Fetal monitoring of a pregnant patient revealed that the fetal heart rate has minimal variability. Which prescribed drug is most likely responsible for the condition? 1 Hydroxyzine (Vistaril) 2 Terbutaline (Brethine) 3 Secobarbital (Seconal) 4 Atropine (Sal-Tropine)

3 Variability in the fetal heart rate can be classified as absent, mild, or moderate variability. This results in hypoxia and metabolic acidemia in the fetus. Central nervous system (CNS) depressants, such as secobarbital (Seconal), cause variability in the fetal heart rate. This medication affects the baseline heart rate in the fetus by less than 5 beats/min. Hydroxyzine (Vistaril), terbutaline (Brethine), and atropine (Sal-Tropine) may result in tachycardia in the fetus. These drugs can increase the baseline fetal heart rate as much as 25 beats/min.

The nurse administers an amnioinfusion to a pregnant patient according to the primary health care provider's (PHP's) instructions. What is the reason behind the PHP's instructions? 1 Late decelerations 2 Early decelerations 3 Variable decelerations 4 Prolonged decelerations

3 Variable decelerations in the fetal heart rate (FHR) are observed when the umbilical cord is compressed. An amnioinfusion refers to the infusion of isotonic fluid into the uterine cavity when the amniotic fluid levels are decreased. This intervention is usually done for the prevention of umbilical cord compression. Late decelerations are observed when infections or elevated uterine contractions (UCs) are seen in a patient. This condition will be reversed by maintaining an I.V. solution, but aminoinfusion is not administered. Early deceleration in the FHR is a normal sign that does not require any intervention. Prolonged deceleration of the FHR occurs when there is a marked reduction of the fetal oxygen supply.

While assessing a pregnant patient who is in labor, the nurse observes W-shaped waves on the fetal heart rate (FHR) monitor. What would the nurse infer from this observation? 1 Placental abruption 2 Dilated cervical layers 3 Umbilical cord compression 4 Elevated uterine contractions

3 W-shaped waves in the FHR monitor are indicative of variable decelerations in the FHR. Variable decelerations are seen when the umbilical cord is compressed at the time of labor. Placental abruption and dilated cervical layers do not cause variable decelerations but may cause late decelerations. Similarly, increased rate of uterine contractions may also cause late decelerations in FHR.

During a prenatal assessment a patient asks the nurse about the disadvantages of spinal anesthesia. What does the nurse teach the patient about the potential effect of spinal anesthesia? 1 It reduces maternal consciousness. 2 It increases maternal muscular tension. 3 It increases probability of operative birth. 4 It increases the possibility of fetal hypoxia.

3 When a spinal anesthetic is given, the need for episiotomy, forceps-assisted birth, or vacuum-assisted birth tends to increase because voluntary expulsive efforts are reduced or eliminated. Maternal consciousness is maintained. Fetal hypoxia is absent as maternal blood pressure is maintained within a normal range. There is no muscular tension; excellent muscular relaxation is achieved.

The primary health care provider (PHP) advised the nurse to assess the maternal temperature and vaginal discharge of a pregnant patient every 2 hours. What is the reason behind this advice? 1 To evaluate fetal status 2 To know the onset of labor 3 To assess for potential risk for infection 4 To prevent fetal hypertension

3 When the membranes rupture, there is a possible risk of infection, as the microorganisms can ascend form the vagina to the uterus. Ruptured membranes can be assessed by monitoring the body temperature and vaginal discharge every 2 hours. The assessment is not used for knowing the onset of labor because it does not indicate the progress of labor. The fetal status is not known by the assessment of the temperature and vaginal show; it may be known by another procedure called Leopold maneuvers. This measure is not done to prevent fetal hypertension, because the maternal body temperature and vaginal discharge does not indicate fetal blood pressure.

The nurse is assessing a pregnant patient through a tocotransducer placed externally and a spiral electrode placed internally. What information would the nurse obtain by this arrangement? Select all that apply. 1 Lactate levels in the fetal blood 2 Strength of uterine contractions 3 Duration of uterine contractions 4 Frequency of uterine contractions 5 Accelerations of fetal heart rate

3, 4, 5 A tocotransducer is an external device that is used for assessment of uterine activity (UA). This instrument would report duration and frequency of the uterine contractions (UCs). The spiral electrode can monitor accelerations of the fetal heart rate. These systems do not report the intensity of UCs. Strength of UCs can be assessed using an intrauterine pressure catheter (IUPC). Neither a tocotransducer nor a spiral electrode is used to determine the lactate level; it is obtained by the fetal scalp sampling method.

A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this? The laceration: 1 Also involves the anterior rectal wall. 2 Continues through the anal sphincter muscle. 3 Extends through muscles of the perineal body. 4 Extends through the skin and structures superficial to muscles

4 A first-degree laceration extends through the skin and structures superficial to muscles. A second-degree laceration extends through muscles of the perineal body. A third-degree laceration continues through the anal sphincter muscle. A fourth-degree laceration involves the anterior rectal wall.

What care must the nurse take when assisting a laboring patient with hydrotherapy? 1 Initiate hydrotherapy in the first stage of labor at 3 cm. 2 Ensure water is warm at 32.5° to 34° C (90.5° to 93.2°F). 3 Check the fetal heart rate (FHR) with internal electrodes. 4 Obtain the approval of the primary health care provider.

4 Agency policy must be consulted to determine if the approval of the laboring woman's primary health care provider is required. The nurse must ensure that all criteria are met in terms of the status of the maternal and fetal unit. Hydrotherapy is usually initiated when the patient is in active labor, at approximately 5 cm. This reduces the risk of a prolonged labor. FHR monitoring is done by Doppler, fetoscope, or wireless external monitor when hydrotherapy is in use. Use of internal electrodes for monitoring FHR is contraindicated in jet hydrotherapy. The temperature of the water should be maintained at 36° to 37° C (96.8° to 98.6° F).

When caring for a patient in the first phase of labor, the nurse observes that the patient is experiencing visceral pain. In which area does visceral pain occur? 1 Abdominal wall and thighs 2 Gluteal area and iliac crests 3 Lumbosacral area of the back 4 Lower portion of the abdomen

4 Visceral pain in the first stage of labor occurs in the lower portion of the abdomen. Visceral pain is a result of distention of the lower uterine segment and stretching of cervical tissue as it effaces and dilates. Pressure and traction on uterine tubes, ovaries, ligaments, nerves, and uterine ischemia also cause visceral pain. Pain that originates in the uterus radiates to the gluteal area, iliac crests, abdominal wall, thighs, lumbosacral area of the back, and lower back. This pain is called referred pain.

The nurse is teaching a group of nursing students regarding fetal oxygenation. The nurse questions a student, "What happens when oxytocin levels are elevated in the patient?" What would be the most appropriate answer given by the nursing student related to the patient's condition? 1 "Hemoglobin levels will decrease." 2 "Blood glucose levels will increase." 3 "Placenta lowers the blood supply." 4 "Uterine contractions (UCs) will increase."

4 An elevated level of oxytocin increases UCs during labor. A reduced hemoglobin level leads to a decreased oxygen supply to the fetus but is not a complication associated with an elevated oxytocin level. Oxytocin has no effect on the blood glucose levels. A family history of diabetes may increase the risk for gestational diabetes in the patient. Conditions such as hypertension in the patient may lower the blood supply to the placenta but are not associated with oxytocin levels.

A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan is considered unrealistic and requires further discussion with the nurse? 1 "My husband and I have agreed that my sister will be my coach because he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." 2 "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." 3 "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." 4 "We do not want the fetal monitor used during labor because it will interfere with movement and doing effleurage."

4 Because monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low-risk pregnancy and as long as labor is progressing normally. Having the woman's sister as her coach, using Lamaze techniques to reduce pain, and using a birthing room are realistic plans for the birth.

What should be the first step taken by the nurse when assessing fetal heart activity using an ultrasound transducer? 1 Auscultate the apical heart rate of the pregnant patient. 2 Apply some conductive gel on the maternal abdomen. 3 Apply some conductive gel on the ultrasound transducer. 4 Locate the maximal intensity area of the fetal heart rate.

4 Before the ultrasonic recording, the nurse should first locate the site on the abdomen where the maximal intensity of the fetal heart rate can be assessed. This should be done to find where the ultrasound transducer head can be placed. The apical heart rate of the patient need not be assessed before this procedure, because this procedure does not interfere with the cardiac activity of the pregnant patient. After finding the site of application, the nurse can apply conductive gel on the transducer and on the abdomen of the patient.

The nurse is caring for a patient in the last trimester of pregnancy. What assessments will the patient display related to the effects of fear and anxiety during labor? An increase in: 1 Blood flow. 2 The progression of labor. 3 Contractions. 4 Muscle tension

4 Fear and excessive anxiety leads to increased muscle tension. It causes more catecholamine secretion. This increases the stimuli to the brain from the pelvis due to increased muscle tension and decreased blood flow. Thus fear and anxiety magnifies the perception of pain. Anxiety does not increase uterine contractions, but reduces the effectiveness of the contractions leading to increased discomfort. This slows the progress of labor.

After reviewing the umbilical cord acid-base report, the nurse confirms that the fetus has respiratory acidosis. Which reading is consistent with the nurse's conclusion? 1 A base deficit value ≥12 mmol/L 2 Blood glucose levels = 120 mg/dL 3 Arterial pH >7.20 4 Partial pressure carbon dioxide >55 mm Hg

4 If pH 2 >55 mm Hg (elevated), and base deficit value respiratory acidosis. In this case, the partial pressure carbon dioxide >55 mm Hg is indicative of respiratory acidosis. A pH >7.20 and base deficit value ≥12 mmol/L are all considered normal. Blood glucose level is not a part of this acid-base report.

The nurse is caring for a multiparous patient. In which stage can the nurse expect the fetal head to be engaged in the pelvic inlet? 1 About 2 weeks before term 2 Before the start of active labor 3 When labor stage I begins 4 After labor is established

4 In a multiparous patient, the abdominal musculature is relaxed. The fetal head often remains freely movable above the pelvic brim and becomes engaged in the pelvic inlet only after labor is established. In a nulliparous patient, the uterus sinks downward and forward about 2 weeks before term, when the presenting part of the fetus descends into the true pelvis. The fetal head is engaged in the pelvic inlet before the onset of active labor. The abdominal muscles are firm in a nulliparous pregnancy and direct the presenting part into the pelvis. The first stage of labor lasts from the onset of regular uterine contractions to full dilation of the cervix.

After observing the reports of the umbilical cord acid-base determination test, the nurse informs the patient that the newborn's condition is normal. Which value indicates the normal condition of the newborn? 1 Umbilical artery: pH, 7.1; Pco2, 50 mm Hg; Po2, 20 mm Hg 2 Umbilical artery: pH, 7.3; Pco2, 40 mm Hg; Po2, 10 mm Hg 3 Umbilical artery: pH, 7.4; Pco2, 52 mm Hg; Po2, 27 mm Hg 4 Umbilical artery: pH, 7.3; Pco2, 45 mm Hg; Po2, 25 mm Hg

4 In the umbilical cord acid-base stimulation method, arterial values indicate the condition of the newborn. Arterial blood pH of 7.2 to 7.3, carbon dioxide pressure (Pco2) value of 45 to 55 mm Hg, and oxygen pressure (Po2) value of 15 to 25 mm Hg approximately indicates the normal fetal condition. Therefore pH of 7.3, Pco2 of 45 mm Hg, and Po2 of 25 mm Hg represent the normal fetal condition. Arterial blood pH of 7.1, Pco2 of 50 mm Hg, and Po2 of 20 mm Hg indicate that the fetus may have respiratory acidosis. Arterial blood pH of 7.4 is indicative of fetal alkalosis.

While assessing a pregnant patient using a fetoscope, the nurse also palpates the abdomen of the patient. What is the purpose of palpating the abdomen of the patient? 1 Detection of fetal heart rate deceleration 2 Evaluation of the severity of the pain caused by active labor 3 Assessment of pain from pressure applied by the fetoscope 4 Assessment of changes in fetal heart rate during and after contraction

4 While assessing the fetal heart rate (FHR) with a fetoscope, the nurse palpates the abdomen of the fetus to evaluate uterine contractions (UCs). This is done to detect any changes in the FHR during and after UCs. FHR decelerations are not identified by palpating the abdomen. It is assessed using the electronic fetal monitoring system. Pain perception is a subjective assessment. Moreover, the pressure from the fetoscope is very minimal and does not cause pain.

The nurse palpates the abdomen of a pregnant patient and reports that the fetus lies in longitudinal position with cephalic presentation. Which observation enabled the nurse to report about the fetal position? 1 The presenting part has deeply descended in the pelvis. 2 The cephalic prominence is on the same side as the back. 3 The head is presenting to the true pelvis and is not engaged. 4 The head feels round, firm, freely movable, and palpable by ballottement

4 Leopold maneuvers (abdominal palpation) help identify the degree of descent into the pelvis of the presenting part in a pregnant patient. The head feels round, firm, freely movable, and palpable by ballottement when the fetus has a cephalic or breech presentation. Based on the descent of the presenting part, it may be difficult to infer the fetal position, as the presenting part can be head or buttock. The cephalic prominence on the same side as the back shows that the fetal head is extended and the face is the presenting part. This maneuver is not related to identification of fetal position. If the head is presenting to the true pelvis and is not engaged, then it determines the attitude of fetal head whether flexed or extended. It does not indicate the fetal position.

During an assessment, the nurse is instructed to determine the position of the fetal head in a pregnant patient. What should the nurse do to determine whether the fetal head is flexed or extended? 1 Palpate the fetal head with the palmar surface of the fingertips of the right hand. 2 Identify the fetal part that occupies the fundus in the uterus of the pregnant patient. 3 Palpate the smooth convex contour of the fetal back using the palmar surface of one hand. 4 Grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly.

4 Leopold maneuvers (abdominal palpation) help identify the degree of descent into the pelvis of the presenting part in a pregnant patient. Therefore the nurse should grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly in order to determine whether the fetal head is flexed or extended. Identifying the fetal part that occupies the fundus of the patient helps to identify the fetal position. The fetal head is palpated with the palmar surface of the fingertips using both hands, but not with only the right hand to determine the cephalic prominence. Palpation of the smooth convex contour of the fetal back and irregularities using the palmar surface of one hand is not used to determine the attitude of the fetal head. This maneuver helps identify the feet, hands, and elbows of the fetus.

A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. The nurse should describe: 1 weight gain of 1 to 3 lbs. 2 quickening. 3 fatigue and lethargy. 4 bloody show.

4 Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.

The nurse assisting a laboring patient is aware that the birth of the fetus is imminent. What is the station of the presenting part? 1. -1 2. +1 3. +3 4. +5

4 Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in centimeters above or below the ischial spines. Birth is imminent when the presenting part is at +4 to +5 cm. When the lowermost portion of the presenting part is 1 cm above the spine, it is noted as minus (-)1. When the presenting part is 1 cm below the spine, the station is said to be plus (+)1. At +3, the presenting part is still descending the birth canal. Birth is imminent when the presenting part is at +4 to +5 cm.

The student nurse finds that the patient who is in labor has sweat on the upper lip, is shivering in the extremities, and is vomiting. What would the student nurse interpret from these observations? The patient has symptoms of: 1 Postural hypotension. 2 Respiratory depression. 3 Onset of the first stage of labor. 4 Onset of the second stage of labor.

4 Sudden appearances of sweat on the upper lip, shaking of the extremities, and vomiting indicate the onset of the second stage of labor. Irregular and mild to moderate uterine contractions (UCs) indicate the onset of the latent phase of the first stage labor. Postural hypotension is characterized by a sudden fall in the blood pressure while changing the position. Respiratory depression is characterized by a decreased rate of respiration.

The nurse is assessing a pregnant patient who has been given terbutaline (Brethine). What is the desired outcome from the administration of the drug? 1 Increased fetal accelerations 2 Reduced placental abruption 3 An Apgar score less than 2 4 A cord blood ph result of 7.2

4 Terbutaline (Brethine) is administered during pregnancy, especially during elective cesarean birth. Terbutaline (Brethine) is known to improve the Apgar score of the fetus to more than 5 and the pH value of the cord to 7.2. Terbutaline (Brethine) has no effect on placental integrity or function. Terbutaline (Brethine) does not cause fetal heart rate (FHR) acceleration. The fetal scalp stimulators are used to improve the accelerations.

The patient reports severe lower back pain during labor. Which position does the nurse plan for the patient during childbirth? 1 Lateral position 2 Upright position 3 Semirecumbent position 4 Hands-and-knees position

4 The hands-and-knees position is suitable for patients with back pain and for patients experiencing back labor, because it reduces stress on the back. The lateral position can be used when the patient is receiving a back rub, but this position does not offer relief from back pain. An upright position may not have a significant effect on back pain. Therefore this position is not planned for childbirth. The semirecumbent position does not support the back, so back pain may not be relieved.

The nurse assesses a pregnant patient and finds that the patient has reduced strength of uterine contractions (UCs). Upon further assessment, the nurse suspects that the patient may have slow progress in labor. Which statement made by the patient indicates the reason for slow progress in labor? 1 "I have a family history of diabetes and hypertension." 2 "I stopped taking folic acid supplements a week ago." 3 "I have been on a diet with high amounts of protein for 15 days." 4 "I am worried a lot this time; I had a lot of problems in my last labor."

4 The nurse suspects that the patient may have slow progress in labor after knowing that the patient is worried and stressed, because she had complications in the previous labor. Stress may reduce the progress in the labor by decreasing the levels of catecholamines. This, in turn, reduces the UCs. Family history of diabetes does not affect the labor progression or UCs. Folic acid supplements are necessary for fetal growth and are given early in pregnancy to prevent neural tube defects. They do not affect the birth process. Taking a diet with a high amount of protein may not affect the onset of labor. Moreover, it helps in the fetal growth and development.

The nurse is performing a vaginal examination of a pregnant patient who is in the first stage of labor. During the examination, the patient reports that she has an urge to bear down. Why does the patient feel this urge? Select all that apply. A The descending part of the fetus reaches the pelvic floor. B The presenting part of the fetus descends into the true pelvis. C Levels of estrogen increase and levels of progestogen decrease. D Levels of progestogen increase and levels of estrogen decrease. E Levels of oxytocin increase due to activation of stretch receptors in the vagina.

A, E When the presenting part of the fetus reaches the pelvic floor, it activates stretch receptors in the posterior vagina and releases endogenous oxytocin in a pregnant woman, which causes the urge bear down and push the baby out. This phenomenon is called the Ferguson reflex. The presenting part of the fetus descends into the true pelvis about 2 weeks before term; this "dropping" does not cause the urge to bear down. Levels of estrogen and progestogen do not change due to vaginal stimulation. Receptors in the vagina are activated rather than inhibited, which releases oxytocin and causes the urge to push.

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