MC: RESOURCE 13, 14, 15, 16, 17, MC: 13, 14, 15, 16, 17
A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because:
"Sedatives help the opioid work better, and they also will assist you to relax and relieve your nausea."
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 would be considered unrealistic and require further discussion with the nurse?
"We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage."
A new mother asks the nurse when the "soft spot" on her son's head will go away. The nurse's answer is based on the knowledge that the anterior fontanel closes after birth by _____ months.
18
In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information?
"Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures."
Nurses can advise their patients that which of these signs precede labor? (Select all that apply.)
A return of urinary frequency as a result of increased bladder pressure. Persistent low backache from relaxed pelvic joints.
The role of the nurse with regard to informed consent is to:
Act as a client advocate and help clarify the procedure and the options.
Which description of the phases of the second stage of labor is accurate?
Active Pushing (Descent) phase: Significant increase in contractions, Ferguson reflux activated, average duration varies.
When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal:
Attitude
Which occurrence is associated with cervical dilation and effacement?
Bloody show
To care for a laboring woman adequately, the nurse understands that the __________ stage of labor varies the most in length?
First
Which description of the four stages of labor is correct for both definition and duration?
First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours
If an opioid antagonist is administered to a laboring woman, she should be told that:
Her pain will return.
The slight overlapping of cranial bones or shaping of the fetal head during labor is called:
Molding
A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dL, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman?
She has thrombocytopenia
Which factors influence cervical dilation (Select all that apply) ?
Strong uterine contractions The force of the presenting fetal part against the cervix The pressure applied by the amniotic sac Scarring of the cervix
With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that:
The effects of the forces determining descent are modified by the shape of the woman's pelvis and the size of the fetal head.
Fetal well-being during labor is assessed by:
The response of the fetal heart rate to uterine contractions
A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?
Turn the woman to the left lateral position or place a pillow under her hip.
Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?
Variability averages between 6 and 10 beats/min.
A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to:
assess the fetal heart rate (FHR) pattern.
The nurse knows that the second stage of labor, the active descent phase, has begun when:
the woman experiences a strong urge to bear down.
With regard to dysfunctional labor, nurses should be aware that:
women who have dysfunctional labor are more likely to deliver via cesarean section. Women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted.
Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?
Active: Moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours
As relates to fetal positioning during labor, nurses should be aware that:
Birth is imminent when the presenting part is at +4 to +5 cm below the spine.
With regard to breathing techniques during labor, maternity nurses should understand that:
Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.
Which presentation is described accurately in terms of both presenting part and frequency of occurrence?
Cephalic: occiput; at least 95%
To teach patients about the process of labor adequately, the nurse knows that which event is the best indicator of true labor?
Cervical dilation and effacement
A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use:
Counterpressure against the sacrum.
Which characteristic is associated with false labor contractions?
Decrease in intensity with ambulation
The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products:
Diminishes as the spiral arteries are compressed.
With regard to systemic analgesics administered during labor, nurses should be aware that:
Effects on the fetus and newborn can include decreased alertness and delayed sucking.
Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that:
Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.
The nurse would expect which maternal cardiovascular finding during labor?
Increased cardiac output
Signs that precede labor include (Select all that apply):
Lightening Bloody show. Rupture of membranes
Vaginal examinations should be performed by the nurse under which of these circumstances? (Select all that apply.)
On maternal perception of perineal pressure or the urge to bear down. When accelerations of the fetal heart rate (FHR) are noted. When membranes rupture.
For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse?
One fetal movement noted in 1 hour of assessment by the mother
In relation to primary and secondary powers, the maternity nurse comprehends that:
Primary powers are responsible for effacement and dilation of the cervix.
In order to care for obstetric patients adequately, the nurse understands that labor contractions facilitate cervical dilation by:
Pulling the cervix over the fetus and amniotic sac.
With regard to a pregnant woman's anxiety and pain experience, nurses should be aware that:
Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on.
The nurse has received report regarding her patient in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and ?2-2. The nurse's interpretation of this assessment is that:
The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines.
In order to evaluate the condition of the patient accurately during labor, the nurse should be aware that:
The endogenous endorphins released during labor will raise the woman's pain threshold and produce sedation.
To help clients manage discomfort and pain during labor, nurses should be aware that:
The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen.
A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of:
a fetal heart rate (FHR) of 180 with absence of variability.
A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe:
bloody show.
A nurse providing care to a woman in labor should be aware that a clinical indication for a cesarean birth:
is performed primarily for the benefit of the fetus and/or mother in the context of clinical conditions.
With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:
its most important function is to afford the opportunity to administer antenatal glucocorticoids.
In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that:
the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:
the examiner's hand should be placed over the fundus before, during, and after contractions.
A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is:
"It is normal to be anxious about labor. Let us discuss what makes you afraid."
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be:
Discharged home to await the onset of true labor.
Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period?
Encourage skin-to-skin contact of mother and baby.
The factors that affect the process of labor and birth, known commonly as the five Ps, include all except:
Pressure
Nurses should be aware of the differences experience can make in labor pain such as:
Sensory pain for nulliparous women often is greater than for multiparous women during early labor.
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:
describe the finding in the nurse's notes.
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:
encouraging the woman to try various upright positions, including squatting and standing.
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is:
hypotension.
A woman is evaluated to be using an effective bearing-down effort if she:
takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction.
Concerning the third stage of labor, nurses should be aware that:
the duration of the third stage may be as short as 3 to 5 minutes. An expectant or active approach to managing this stage of labor reduces the risk of complications.
The maternity nurse should notify the health care provider about which assessment findings during labor? (Select all that apply.)
Blood glucose level of 78 mg/dL Oral temperature of 99.8° F
For vaginal birth to be successful, the fetus must adapt to the birth canal during the descent. The turns and other adjustments necessary in the human birth process are termed the "mechanism of labor." Please list the seven cardinal movements in the mechanism of labor in the correct order.
Flexion/ Three Internal rotation/ four External rotation/ six Expulsion/ seven Engagement/ One Descent/ Two Extension/ five
While providing care to a patient in active labor, the nurse should instruct the woman that:
Frequent changes in position will help relieve her fatigue and increase her comfort.
In the current practice of childbirth preparation, emphasis is placed on
Having expectant parents attend childbirth preparation in any or no specific method.
Which statement is most likely to be associated with a breech presentation?
High rate of neuromuscular disorders
Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help clients. Nurses should know that _____ women may be stoic until late in labor, when they may become vocal and request pain relief.
Hispanic
For the labor nurse, care of the expectant mother begins with which situations? (Select all that apply.)
Observation of bloody, or pink, show The onset of progressive, regular contractions
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?
The fetal presenting part is 1 cm above the ischial spines.
The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if:
The mother and family's priorities and preferences are incorporated into the plan.
The primary difference between the labor of a nullipara and that of a multipara is the:
Total duration of labor.
A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use:
counterpressure against the sacrum.
Which test is performed to determine if membranes are ruptured?
Fern test
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? (Select all that apply.)
Fetal fibronectin is present in vaginal secretions. History of preterm labor experience with a prior pregnancy.
When monitoring a woman in labor who has just received spinal analgesia, the nurse should report which assessment findings to the health care provider? (Select all that apply.)
Fetal heart rate of 100 beats/min Respiratory rate of 14 breaths/min
A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should:
Help her breathe into a paper bag
After delivering a healthy baby boy with epidural anesthesia, a woman on the after birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.)
Keeping the head of bed elevated at all times Assisting with a blood patch procedure Avoid caffeine
Which statement correctly describes the effects of various pain factors?
Levels of pain-mitigating b-endorphins are higher during a spontaneous, natural childbirth.
Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory?
Massaging the woman's back
Which statement is the best rationale for assessing maternal vital signs between contractions?
Maternal circulating blood volume increases temporarily during contractions.
A woman in active labor receives an analgesic opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?
Meperidine (Demerol)
A woman in labor has just received an epidural block. The most important nursing intervention is to:
Monitor the maternal blood pressure for possible hypotension.
A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate?
Naloxone (Narcan)
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take?
Notify the primary health care provider immediately (HCP).
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority?
Place the woman in the knee-chest position.
Which basic type of pelvis includes the correct description and percentage of occurrence in women?
Platypelloid: flattened, wide, shallow; 3%
The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? (Select all that apply.)
Previous cesarean birth Unstable coronary artery disease
When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother's right side close to midline. What is the likely position of the fetus?
RSA
An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, "My contractions are so strong that I don't know what to do with myself." The nurse should:
Recognize that pain is personalized for each individual.
With regard to factors that affect how the fetus moves through the birth canal, nurses should be aware that:
The normal attitude of the fetus is called general flexion.
Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?
The vulva bulges and encircles the fetal head.
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:
change in position.
The nurse's priority action when observing early deceleration indicating expected head compression during contractions is to:
change maternal position.
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:
fentanyl (Sublimaze).
With regard to what might be called the tactile approaches to comfort management, nurses should be aware that:
hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited.
A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to:
help the woman breathe into a paper bag.
When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to:
initiation of epidural anesthesia that resulted in maternal hypotension.
A nurse caring for a woman in labor understands that moderate variability of the fetal heart rate might be caused by:
methamphetamines.
The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: (Select all that apply.)
passenger position of the mother psychologic response powers passageway
The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be:
progressive uterine contractions with cervical change.
After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is:
referred.
Nurses should be aware of the different experience can make in labor pain, such as:
sensory pain for nulliparous women often is greater than for multiparous women during early labor.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to:
stop the Pitocin.
