Maternity - Intrapartum
Which assessment following an amniotomy should be conducted first? 1.Cervical dilation 2.Bladder distention 3.Fetal heart rate pattern 4.Maternal blood pressure
Fetal heart rate pattern Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.
The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1.Bear down. 2.Breathe rapidly. 3.Hold your breath. 4.Push with each contraction.
Breathe rapidly. During a precipitous labor, when the infant's head crowns the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and the fetus.
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age
Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.
The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. 5.Allow out-of-bed activity as tolerated.
Keep the room semi-dark. Initiate seizure precautions. Pad the side rails of the bed. Avoid environmental stimulation. Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1.Notify the health care provider (HCP). 2.Continue monitoring the fetal heart rate. 3.Encourage the client to continue pushing with each contraction. 4.Instruct the client's coach to continue to encourage breathing techniques.
Notify the health care provider (HCP). A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply. 1.Station 2.Dilation 3.Effacement 4.Bloody show 5.Contraction effort
Station Dilation Effacement The vaginal examination for a client in labor specifically determines effacement 0% to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1.Supine position with a wedge under the right hip 2.Trendelenburg's position with the legs in stirrups 3.Prone position with the legs separated and elevated 4.Semi Fowler's position with a pillow under the knees
Supine position with a wedge under the right hip Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi Fowler's position is not practical for this type of abdominal surgery
The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. 1.Early labor 2.Amniotomy 3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies
Tachycardia Fetal hypoxia Metabolic acidemia Congenital anomalies The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into 4 different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition.
After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1.Reposition the laboring woman to knee-chest. 2.Assess the vagina and cervix with a gloved hand. 3.Notify the health care provider of the need for an amnioinfusion. 4.Document the description of the fetal bradycardia in the nursing notes.
Assess the vagina and cervix with a gloved hand. It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.
The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1.Noting whether the heart rate is greater than 140 beats/minute 2.Placing the diaphragm of the Doppler on the mother's abdomen 3.Palpating the maternal radial pulse while listening to the FHR 4.Performing Leopold's maneuvers first to determine the location of the fetal heart
Palpating the maternal radial pulse while listening to the FHR The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/minute or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuvers may help the examiner to locate the position of the fetus but will not ensure a distinction between the 2 heart rates.
The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1.Monitor fetal heart rate continuously. 2.Monitor maternal vital signs frequently. 3.Perform a vaginal examination every shift. 4.Administer an antibiotic per HCP prescription and per agency protocol.
Perform a vaginal examination every shift. Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.
A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action? 1.Sit the client in a high Fowler's position. 2.Call the pharmacy for a tocolytic medication. 3.Get intravenous (IV) therapy equipment and solution from the storage area. 4.Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.
Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help accomplish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified Sims' position. The health care provider is also notified immediately. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.
The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the health care provider (HCP)? Select all that apply. 1.Clear, dark amber amniotic fluid 2.Amniotic fluid volume of 800 mL 3.Light green amniotic fluid with no odor 4.Thick white amniotic fluid with no odor 5.Straw-colored amniotic fluid with flecks of vernix
Clear, dark amber amniotic fluid Light green amniotic fluid with no odor Thick white amniotic fluid with no odor Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin, watery consistency and may have a mild odor. The normal amount of amniotic fluid ranges from 500 to 1000 mL. Dark amber color, light green color, and thick white color are not descriptions of normal amniotic fluid and should be brought to the HCP's attention.
A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1.Contact the obstetrician. 2.Continue to monitor the client. 3.Report the FHR to the anesthesiologist. 4.Prepare for imminent delivery of the fetus.
Continue to monitor the client. The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.
A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider has prescribed an epidural block. Which nursing intervention should be implemented after the epidural block has been placed? 1.Palpate the bladder at frequent intervals. 2.Encourage the woman to walk to progress the labor. 3.Assess the blood pressure frequently for hypertension. 4.Encourage the woman to assume a supine position after the epidural has been placed.
Palpate the bladder at frequent intervals. The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The woman loses the sensation that she needs to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Ambulation is not allowed because of the anesthesia. The woman is encouraged to lie on her side to increase placental perfusion to the fetus. Hypotension, not hypertension, is a concern.
The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? 1.Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation
Placental separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.
During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1.Stimulate the labor process. 2.Prevent dehydration and hypoxemia. 3.Avoid the necessity of a cesarean section. 4.Eliminate the need for analgesic administration.
Prevent dehydration and hypoxemia. A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration.
The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Promote ambulation every 30 minutes. 4.Monitor the oxytocin infusion closely
Provide pain relief measures. Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.
On March 10, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7 the previous year. The nurse plans care based on which interpretation? 1.The client is possibly in preterm labor. 2.The fetus may not be viable at delivery. 3.The client may require labor augmentation. 4.The fetus is at high risk for shoulder dystocia.
The client is possibly in preterm labor. According to Nägele's rule, by subtracting 3 months and adding 7 days and 1 year to this client's LMP the nurse can determine that her estimated date of delivery (EDD) is April 14. This client is in the labor and delivery unit to be evaluated for the presence of labor more than 1 month before her EDD; therefore, she is possibly in preterm labor. Viability is said to occur between the 22nd and 25th weeks of gestation. This fetus is approximately 4 weeks before term. If this client truly is in labor, the health care provider's plan would be to try to stop the labor in order to prevent delivery at this early stage in the pregnancy. This would eliminate option 3, labor augmentation. Because of the typical 36-week gestational size of a fetus, 2200 to 2900 g, there would be no risk for a difficult shoulder delivery
