Nursing Management During Labor and Birth

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.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

6.5

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.

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications.

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries."

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?

Acceleration of at least 15 bpm for 15 seconds

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs.

Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of delivery of the fetus and ends with the time of the delivery of the

At which time in a client's labor process would the nurse encourage effleurage?

During the early labor phase

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.

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

Respiratory status

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR.

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

The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?

just before birth

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

maternal hypotension and fetal bradycardia

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

prolonged decelerations

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

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?

starting an IV and hanging IV fluids