Maternity
A client is bleeding excessively after the birth of her newborn. The healthcare provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin at a rate of 100 mL/hr. The nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? Checking for a distended bladder.
A displaced and boggy uterus is usually the result of a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus. If still boggy, the uterus should be massaged until firm. The oxytocin infusion may need to be increased if voiding and fundal massage are ineffective; however, the healthcare provider must be notified to change the order. Continuing to perform fundal massage is necessary if the fundus remains boggy after the client has voided. Continuing to assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the priority.
When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? The bladder has become over distended.
A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced, and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment regarding overstretched uterine ligaments.
In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action at this time? Having the client empty her bladder
A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding. Therefore the bladder should be emptied to improve uterine tone. Watching for signs of retained secundines may be done if emptying the bladder does not rectify the situation. If parts of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding may be evident. Vigorous massage tires the uterus, and even with massage the uterus is unable to contract over a full bladder. Explaining to the client that this is a sign of uterine stabilization is not accurate; the uterus will not remain contracted over a full bladder.
While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats per minute that lasts 15 seconds. How should the nurse document this event? An acceleration
An acceleration is an abrupt increase in FHR above the baseline of 15 beats/min for 15 seconds; if the acceleration persists for more than 10 minutes, it is considered a change in baseline rate. Early decelerations, not increases, occur. An early deceleration starts before the peak of the uterine contraction and returns to baseline when the uterine contraction ends. A sonographic motion is not a term used in fetal monitoring. A tachycardic FHR is one faster than 160 beats per minute.
What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has been successful? "I will apply warm packs and massage my breast before each feeding"
Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool shower before each feeding will contract the milk ducts and interfere with the let-down reflex. Heavy consumption of milk products is not required to stimulate the production of milk. Breast binders may inhibit lactation by fooling the body into thinking that milk secretion is no longer needed.
A client is admitted to the birthing unit in active labor. Which physiologic changes should the nurse anticipate after an amniotomy is performed? Progressive dilation & effacement
Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater because contractions usually increase in intensity and frequency after the membranes are artificially ruptured.
What common problem affects the client in labor when an external fetal monitor has been applied to her abdomen? Intrusion on movement
Because the client is attached to a machine and movement may alter the tracings, movement is discouraged. Placement of the external monitor leads does not interfere with the administration of sedatives. An external monitor does not interfere with breathing techniques. An external monitor does not necessitate more frequent vaginal examinations.
A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action? Notifying the healthcare provider
Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.
A pregnant client asks the clinic nurse how smoking will affect her baby. What information about cigarette smoking will influence the nurse's response? The resulting vasoconstriction affects both fetal and maternal blood vessels
Cigarette smoking or continued exposure to secondary smoke causes both maternal and fetal vasoconstriction, resulting in fetal growth retardation and increased fetal and infant mortality. There is no clinical evidence that smoking relieves tension or that the fetus is more relaxed. Smoking causes vasoconstriction; permeability of the placenta to smoke is irrelevant. Although the fetal and maternal circulations are separate, vasoconstriction occurs in both mother and fetus.
What is the optimal nursing intervention to minimize perineal edema after an episiotomy? Applying ice packs
Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.
During an emergency birth the fetal head is crowning on the perineum. How should the nurse support the head as it is being delivered? By distributing the fingers evenly around the head
Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from "popping out," which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate.
The nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond? "During the 8th week of pregnancy"
During the eighth week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the second week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.
Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? Reposition the client from supine left lateral.
Hypotension is a common side effect of epidural anesthesia that results in decreased placental perfusion and late decelerations on the fetal monitor. The priority intervention is repositioning the client to relieve compression of the vena cava and increase venous return, which in turn increases placental perfusion. Administering oxygen and increasing the flow rate are correct interventions, but neither is the priority because these interventions would not be effective until compression of the vena cava has been relieved and placental perfusion increased. Assessing the maternal blood pressure for a systolic pressure below 100 mm Hg only provides data and does not correct the late deceleration.
A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram? Increase fluid intake for 1 hour before the procedure.
In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation.
A multigravida in the active phase of labor says, "I feel all wet. I think I wet myself." What should the nurse do first? Inspect her perineal area
Inspection of the perineum is performed to determine whether rupture of the membranes has occurred and whether the umbilical cord has prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the priority, although it is done eventually if the membranes have ruptured. An oral temperature should be taken after it has been established that the membranes have ruptured.
The nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first? Reposition her on her left side.
Late decelerations may indicate impaired placental profusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the practitioner is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented. Elevating the head of the bed will increase pressure on the vena cava and aorta, further reducing placental perfusion. Oxygen may be administered if placing the client on her left side does not resolve the late decelerations.
A pregnant client uses a computer while sitting almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend? "Try to walk around every few hours during the workday."
Maintaining the sitting position for prolonged periods may constrict the vessels of the legs, particularly in the popliteal spaces, as well as diminish venous return. Walking causes the leg muscles to contract and applies gentle pressure to the veins, thereby promoting venous return. A better means of improving circulation is to walk around several times each morning and afternoon; the legs may be elevated while the client is sitting at her desk. If the client is feeling well, there are no contraindications to working throughout her pregnancy. Adequate nourishment can be obtained during mealtimes; the client does not require extra nutrition breaks.
The nurse is teaching participants in a prenatal class regarding breastfeeding versus formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which response is most appropriate? "Breastfed infants have fewer infections."
Maternal antibodies are transferred from the mother in breast milk, providing protection for a longer time than do antibodies transferred to the fetus by way of the placenta. The neonate is protected by the antibodies. The fetus' own antibody system is immature at birth. Women who breastfeed completely (day and night with no supplementary feedings) may avoid ovulation and resumption of the menstrual cycle. Use of formula or solid foods decreases breastfeeding frequency and can lead to ovulation. Ovulation generally occurs before menses, making it difficult to know when the menstrual cycle is resuming. Therefore, breastfeeding is considered one of the least reliable methods of contraception for the new mother. Because of the higher carbohydrate content of breast milk, which is digested rapidly, breastfed infants wake more frequently than formula-fed infants. Their feeding demands take more time to regulate than do the formula-fed infant's. Breast milk has 1.1 g protein/100 mL; cow's milk has 3.5 g/100 mL. Whole cow's milk is unsuitable for infants.
What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? Moderate serosa
On the third to fourth day the uterine discharge becomes pink to brown; it continues until approximately the 10th day. After about 10 days the uterine discharge becomes yellow to white (alba); alba may continue until 2 to 6 weeks after the birth. It is unusual to have scant lochia rubra. Lochia rubra lasts from the first to about the third day; it is usually heavy but may be moderate after a few days.
A client in active labor has requested epidural anesthesia for pain management . The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation? There is a risk of hypotension, & the large amount of IV fluid reduces this risk.
Once an epidural is initiated there is a risk of hypotension (low blood pressure), which may result in fetal distress. This risk is reduced by the administration of 500 to 2000 mL. Epidural medication is administered through a catheter placed by the anesthetist. Quoting institutional policy does not provide the explanation for administering the solution. Providing 500 mL of fluid is useful in counteracting the risk of hypotension; however, it is not given as a means of determining that the line is patent before the administration of medication.
The nurse is teaching a client to care for her episiotomy after discharge. Which priority instruction should the nurse include in her instructions? Perform perineal care after toileting until healing occurs.
Prevention of infection is the priority. Resting should be encouraged; however, it is not the priority at this time. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. Which information regarding true labor contractions should the nurse include in a response to the client's question? Accompanied by progressive cervical dilation.
Progressive cervical dilation is the only positive sign of true labor; the cervix dilates in response to regular, coordinated uterine contractions. The contractions of true labor increase in length and intensity. A continuous contraction may have an adverse effect on the fetus; immediate intervention is required. The membranes may rupture before contractions begin; more frequently they rupture after true labor is established.
During the second stage of labor the nurse discourages the client from holding her breath longer than 6 seconds while pushing with each contraction. Which complication does this prevent? Fetal hypoxia
Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus.
A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what? Neural tube defects
The alpha-fetoprotein test can detect not only neural tube defects, but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.
A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take? Discontinuing the test because the pattern is within the normal range
The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.
As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention? Turn her onto her left side
The client is experiencing supine hypotension, which is caused by compression of the large vessels by the gravid uterus. A side-lying position will relieve the pressure on the vessels, increase venous return, improve cardiac output, and increase blood pressure. S/S: Pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy skin, sweating. Interventions: position woman on her side until s/s subside & vital signs stabilize within normal limits.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? First
The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.
Which statements regarding the involution process are correct? Involution begins immediately after expulsion of the placenta. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a non-pregnant state after birth.
The involution process is the return of the uterus to a non-pregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.
A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part? At the level of the ischial spines
The ischial spines are used as landmarks in relation to the fetus's head, because they reflect the progression of labor; 0 station indicates that the presenting part is at the ischial spines. When the head enters the vagina it is below the ischial spines and its position is designated with positive numbers (+1 to +4). When the presenting part is floating, the fetus is at -5 station. A position above the ischial spines is designated by a minus number (-1 to -4)
A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond? "Your diaphragm has been displaced upward."
The pressure of the enlarging fetus causes upward displacement of the diaphragm, which results in thoracic breathing; this limits the descent of the diaphragm on inspiration. The lower rib cage expands; it does not become restricted. There is no change in the size of the lungs during pregnancy. The thoracic cage enlarges; it does not rise.
A client in active labor starts screaming, "The baby is coming! Do something!" What is the nurse's primary action? Checking the perineal area for the presenting part
The primary action by the nurse should be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse should remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.
