NSG 333 Ch 14- Nursing Management During Labor and Birth

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?

Difficulty breathing Explanation: Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign. A decreased level of consciousness will occur later. A staggering gait or intense pain is not a primary symptom.

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?

Green-colored fluid in the vagina Explanation: Green-tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions are expected at this stage of labor.

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds?

In the woman's lower abdominal quadrant Rationale: The fetal heart rate is heard most clearly at the fetal back. In a cephalic presentation, the fetal heart rate is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

A nurse palpates a woman's fundus to determine contraction intensity. What would be most appropriate for the nurse to use for palpation?

finger pads Rationale: To palpate the fundus for contraction intensity, the nurse would place the pads of the fingers on the fundus and describe how it feels. Using the finger tips, palm, or back of the hand would be inappropriate.

Which action is a priority when caring for a woman during the fourth stage of labor?

assessing the uterine fundus Rationale: During the fourth stage of labor, a priority is to assess the woman's fundus to prevent postpartum hemorrhage. Offering fluids, encouraging voiding, and assisting with perineal care are important but not an immediate priority.

As a woman enters the second stage of labor, which would the nurse expect to assess?

feelings of being frightened by the change in contractions Explanation: The nature of contractions changes so drastically— the urge to push is very strong—that this can be frightening.

To assess the frequency of a woman's labor contractions, the nurse would time:

the beginning of one contraction to the beginning of the next. Explanation: Measuring from the beginning of one contraction to the next marks the time between contractions.

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes Explanation: The fetus is at highest risk for umbilical cord prolapse after the rupture of membranes. It is important to assess the fetal heart rate for one full minute. The other options are not as high of a risk.

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering?

antiretroviral Explanation: Women who are HIV-positive are given a combination of antiretroviral drugs. To further reduce the risk of perinatal transmission, ACOG and the U.S. Public Health Service recommend that women who are infected with HIV and have plasma viral loads of more than 1,000 copies/ml be counseled regarding the benefits of elective cesarean birth. Antibiotics would not be used. Ataractics and benzodiazepines would be used for systemic analgesia.

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

"The temperature of the water should be at least 105 *F (40.5 *C)." Answer: D Rationale: Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105 *F (40.5 *C) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.

A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique?

"Inhale through your nose and exhale through pursed lips." Rationale: Many couples learn patterned-paced breathing during their childbirth education classes. Three levels may be taught, each beginning and ending with a cleansing breath or sigh after each contraction. In the first pattern, also known as slow-paced breathing, the woman inhales slowly through her nose and exhales through pursed lips. The breathing rate is typically 6 to 9 breaths/min. In the second pattern, the woman inhales and exhales through her mouth at a rate of 4 breaths every 5 seconds. The rate can be accelerated to 2 breaths/sec to assist her to relax. The third pattern is similar to the second pattern except that the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. All breaths are kept equal and rhythmic and can increase as contractions increase in intensity.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

"It distracts your brain from the sensations of pain." Explanation: Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?

"Our baby will come out face first." Explanation: The fetal presentation pertains to the part of the fetus that comes through the cervix and the birth canal first. A face presentation indicates that the face presents first. The face is a large part of the head, so caution must be used.

The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?

"The baby is coming. I'll explain what's happening and guide you." Explanation: Continuous labor support with a trained nurse or doula has been shown to be effective in increasing coping ability of laboring woman. To keep her calm, the nurse needs to explain all procedures and discuss all events to the mother. The nurse cannot know the final outcome and should be careful of making general statements indicating everything will be OK. It is the nurse's responsibility to calm the client down and not wait for the health care provider. While calling the family may help, there is no guarantee and the nurse needs to work to calm the client down.

A nurse is explaining the use of effleurage as a pain relief measure during labor. Which statement would the nurse most likely use when explaining this measure?

"The technique involves light stroking of the abdomen with breathing." Rationale: Effleurage involves light stroking of the abdomen in rhythm with breathing. Therapeutic touch is an energy therapy and is based on the premise that the body contains energy fields that lead to either good or ill health and that the hands can be used to redirect the energy fields that lead to pain. Attention focusing and imagery involve focusing on a specific stimulus. Massage focuses on manipulating body tissues.

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?

"Unfortunately, I'm going to have to stay quite still in bed while it is in place." Rationale: With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.

A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful?

"We can get up and walk around after receiving combined spinal-epidural analgesia." Rationale: When compared with traditional epidural or spinal analgesia, which often keeps the woman lying in bed, combined spinal-epidural analgesia allows the woman to ambulate ("walking epidural"). Patient-controlled epidural analgesia provides equivalent analgesia with lower anesthetic use, lower rates of supplementation, and higher client satisfaction. Pudendal nerve blocks are used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor. Local infiltration using lidocaine does not alter the pain of uterine contractions, but it does numb the immediate area of the episiotomy or laceration.

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:

-2 station Rationale: The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less. Explanation: In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Check the fetal heart rate Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

Clear to straw-colored fluid Explanation: The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.

A client arrives at a health care facility in the latent phase of the first stage of labor. Which intervention should the nurse implement?

Provide emotional and physical support. Explanation: The nurse should provide emotional and physical support. When pain exceeds the client's threshold for coping, she may require pharmacologic measures to facilitate pain relief. Cesarean birth is not indicated during the latent phase of labor, so the nurse need not assist in preparation for it. Clients receiving epidural anesthesia generally should be in the active phase of the first stage of labor with cervical dilation of 4 to 5 cm, so there is no need to assist in providing epidural anesthesia. Naloxone may be used to reverse the effects of both maternal and neonatal respiratory depression following the administration of opioid agents for pain relief.

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes Explanation: Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord. The client may remain at home for all other options.

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR?

between the umbilicus and the symphysis pubis Rationale: The ultrasound transducer is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The tocotransducer is placed over the uterine fundus in the area of greatest contractility.

When planning the care of a woman in the latent phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?

every 30 to 60 minutes Rationale: FHR is assessed every 30 to 60 minutes during the latent phase of labor and every 15 to 30 minutes during the active phase. The woman's temperature is typically assessed every 4 hours during the first stage of labor and every 2 hours after ruptured membranes. Blood pressure, pulse, and respirations are assessed every hour during the latent phase and every 30 minutes during the active and transition phases. Contractions are assessed every 30 to 60 minutes during the latent phase and every 15 to 30 minutes during the active phase, and every 15 minutes during transition

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed Explanation: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks?

ischial spine Explanation: Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the midpelvis. The ischial spines serve as landmarks and have been designated as 0 station.

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels Explanation: During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.

The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant. Explanation: The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia Explanation: Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

meperidine Explanation: Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the opioid or reduce anxiety.

A nurse is reading a journal article about the various medications used for pain relief during labor. Which drug would the nurse note as producing amnesia but no analgesia?

midazolam (Versed) Rationale: Midazolam is given intravenously and produces good amnesia but no analgesia. It is most commonly used as an adjunct for anesthesia. Prochlorperazine is typically given with an opioid such as morphine to counteract the nausea of the opioid. Fentanyl and meperidine are opioids that produce analgesia.

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?

moderate Rationale: A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong or intense contraction feels like the forehead.

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which area?

muscles of perineal body Rationale: The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a second-degree laceration extends through the muscles of the perineal body; a third-degree laceration continues through the anal sphincter muscle; and a fourth-degree laceration also involves the anterior rectal wall.

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

naloxone Rationale: Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid.

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations Explanation: Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?

respiratory depression Rationale: Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate Explanation: The nurse must monitor for respiratory depression. Monitoring the client's respiratory rate will be the best indicator of respiratory depression.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?

rupture of membranes Explanation: The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration?

variable decelerations Rationale: Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns. Early decelerations are visually apparent, usually symmetrical and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs, with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency. Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes.

Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply.

walking with partner support straddling with forward leaning over a chair rocking back and forth with foot on chair Rationale: Positioning during the first stage of labor includes walking with support from the partner, side-lying with pillows between the knees, leaning forward by straddling a chair, table, or bed or kneeling over a birthing ball, lunging by rocking weight back and forth with a foot up on a chair or birthing ball, or an open knee-chest position.

Which suggestion by the nurse about pushing would be most appropriate to a woman in the second stage of labor?

"Choose whatever method you feel most comfortable with for pushing." Rationale: The role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push. In the absence of any complications, nurses should not be controlling this stage of labor, but empowering women to achieve a satisfying experience. Common practice in many labor units is still to coach women to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that is not supported by research. Research suggests that directed pushing during the second stage may be accompanied by a significant decline in fetal pH and may cause maternal muscle and nerve damage if done too early. Effective pushing can be achieved by assisting the woman to assume a more upright or squatting position. Supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best?

"The analgesia will reduce the sensation of pain for a limited period of time." Explanation: It is best to prepare the client for the role of analgesia in her labor experience. It is best to explain that analgesia will reduce, not block or eliminate, the pain sensation for a limited period of time depending upon the medication selected. Stating the inability to get out of bed does not answer the client's question about pain relief.

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used.

-4 station -2 station 0 station +2 station +4 station Explanation: Progressive fetal descent (-5 to +4) is the expected norm during labor, moving downward from the negative stations to zero station to the positive stations in a timely manner.

A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines which information with the first maneuver?

Fetal presentation Rationale: Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. The first maneuver determines presentation; the second maneuver determines position; the third maneuver confirms presentation by feeling for the presenting part; the fourth maneuver determines attitude based on whether the fetal head is flexed and engaged in the pelvis.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. Explanation: In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler position owing to the risk of supine hypotension in the supine position and in Trendelenburg position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depres

The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which technique during labor?

Attention focusing Explanation: Attention focusing is the use of an object or picture or image for the woman to reflect and focus on (internally or externally) during labor to distract her from the labor pain. Hypnosis is a psychological state. Water therapy involves the woman sitting in water to relax. Patterned breathing involves the woman controlling her breathing patterns during contractions and "breathing through" them to help control the pain. The attention focusing, patterned breathing, water therapy, and hypnosis are all variations of relaxation which may be used by the client during the birthing process.

The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?

Continue with the admission assessment Explanation: The nurse should continue with the assessment to establish a baseline for the client and determine her status. This could include asking any personal questions that might be inappropriate to ask in front of the doula. Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A doula does not take the place of a nurse or client's partner but is there to assist in the process. There would be no need to print off any instructions for the doula to sign.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority?

FHR Explanation: When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6 to 25 beats per minute. Explanation: Variability is described in four categories: absent, fluctuations range undetectable; minimal, fluctuations range observed at <5 beats per minute; moderate (normal), fluctuation range from 6 to 25 beats per minute; and marked, fluctuation range >25 beats per minute.

When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being?

Fetal heart rate acceleration occurs. Explanation: The fetus is stimulated via an acoustic vibrator. From the stimulation, the fetal heart rate accelerates. If the acceleration occurs, fetal acidosis is not present. Fetal movement is limited in the birth canal. Decelerations do not indicate well-being. Acoustic vibrations do not descend the fetus into the birth canal.

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

Dilation (dilatation) of cervix Explanation: The best determination of effective contractions is dilation (dilatation) of the cervix. Engagement, membrane rupture, and bloody show may all occur before the cervix has dilated.

Which nursing action is applied throughout all stages of labor?

Do not allow the client to lay flat on her back for long periods. Explanation: Throughout the labor process, the client is not to lay flat on her back due to supine hypotension. This places weight on the great vessels and decreases blood flow. It is acceptable to place a pillow or wedge under one hip, thus distributing the client's weight to one side. The client may do the other options at different points throughout the labor process.

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?

Encourage her through the contractions, explaining why she cannot receive any pain medication. Explanation: At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?

Have the client pant and blow through the contraction. Explanation: The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Help the woman change positions. Explanation: First, the nurse should assist the woman to change positions and try to find a position that is comfortable for the woman that relieves the compression. If the variables stop after the position change, the nurse will know that the compression has been relieved. However, if the variables continue, the nurse should try a variety of position changes, including the knee-chest position.

A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"?

Inspect the perineum. Explanation: The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, she can then assess the heart sounds, contraction rate, and contact the primary care provider—if there is time.

Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?

Massage the woman's back. Explanation: Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Medication should be withheld until all nonpharmacologic treatments have been exhausted.

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?

Neonatal depression is possible. Explanation: General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate?

Notify the health care provider about possible meconium. Rationale: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

Palpate the mother's radial pulse at the same time. Explanation: To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?

Respiratory status Explanation: Opioids like fentanyl have significant effects on the client's respiratory status. This is the priority assessment because the other parameters are affected to a lesser degree.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?

The mother may have difficulty working effectively with contractions. Explanation: Breathing and relaxation techniques can speed labor. An inability of the woman to do these as a result of pain relief measures can slow labor.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

This may prolong labor and increase complications. Explanation: Administration of pharmacologic agents such as narcotics too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor.

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as:

a possible infection Rationale: Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy (a disposable plastic hook [Amnihook] is used to perforate the amniotic sac). Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:

instruct the client or her partner to perform light fingertip repetitive abdominal massage. Explanation: Effleurage is light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation. Controlled chest breathing is a technique used in Lamaze breathing. Pressing on trigger points is an acupressure technique.

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is found to be HIV-positive. Which action would the nurse expect to include when developing a plan of care for this woman? Select all that apply.

avoiding scalp electrodes for fetal monitoring refraining from obtaining fetal scalp blood for pH testing administering antiretroviral therapy at the onset of labor Rationale: To reduce perinatal transmission, HIV-positive women are given a combination of antiretroviral drugs. To further reduce the risk of perinatal transmission, ACOG and the U.S. Public Health Service recommend that HIV-infected women with plasma viral loads of more than 1,000 copies per milliliter be counseled regarding the benefits of elective cesarean birth. Additional interventions to reduce the transmission risk would include avoiding use of scalp electrode for fetal monitoring or doing a scalp blood sampling for fetal pH, delaying amniotomy, encouraging formula feeding after birth, and avoiding invasive procedures such as forceps or vacuum-assisted devices.

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:

blue. Rationale: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain yellow to olive green suggests that the membranes are most likely intact.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present?

cervical dilation of 2 cm or more Rationale: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.

A nurse is assisting with the birth of a newborn. The fetal head has just emerged. Which action would be performed next?

checking for the cord around the neck Rationale: Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. Then the health care provider suctions the newborn's mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium. Finally the umbilical cord is double-clamped and cut between the clamps. The newborn is placed under the radiant warmer, dried, assessed, wrapped in warm blankets, and placed on the woman's abdomen for warmth and closeness.

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply.

fundal height measurement membrane status contraction pattern Rationale: As part of the admission physical assessment, the nurse would assess fundal height, membrane status, and contractions. Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history.

The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply.

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus Explanation: Leopold maneuvers help the nurse to determine the presentation, position, and lie of the fetus. The approximate weight and size of the fetus can be determined with ultrasound sonography or abdominal palpation.

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:

effleurage. Explanation: Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.

A nurse notes a pregnant client has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?

encouraging the client to push when they have a strong desire to do so Explanation: During the second stage of labor, nursing interventions focus on motivating the client and encouraging the client to put all their efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the client's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.

At which time interval will the nurse assess the fetal heart rate of pregnant clients who are in the early active phase of labor?

every 15 to 30 minutes Explanation: During the active phase of labor, fetal heart rate (FHR) is monitored every 15 to 30 minutes. FHR is assessed every 30 to 60 minutes during the latent phase of labor. The client's temperature is typically assessed every 4 hours during the first stage of labor and every 2 hours after the membranes have ruptured. Blood pressure, pulse, and respirations are assessed every hour during the latent phase and every 30 minutes during the active phase. Contractions are assessed every 30 to 60 minutes during the latent phase, every 15 to 30 minutes during the active phase, and every 10 to 15 minutes during late active phase.

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomen Explanation: In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.

A nurse is conducting a class for a group of nurses who are newly hired for the labor and birth unit. After teaching the group about fetal heart rate patterns, the nurse determines the need for additional teaching when the group identifies which finding as indicating normal fetal acid- base status? Select all that apply.

sinusoidal pattern recurrent variable decelerations fetal bradycardia Rationale: Predictors of normal fetal acid-base status include a baseline rate between 110 and 160 bpm, moderate baseline variability, and absences of later or variable decelerations. Sinusoidal pattern, recurrent variable decelerations, and fetal bradycardia are predictive of abnormal fetal acid-base status.

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?

sudden gush of dark blood from the vagina Rationale: Signs that the placenta is separating include a firmly contracting uterus; a change in uterine shape from discoid to globular ovoid; a sudden gush of dark blood from the vaginal opening; and lengthening of the umbilical cord protruding from the vagina.