OB unit 2 quiz
b. active phase Respiratory depression of the newborn will not occur if the medication is given during the active phase; it should not be given when birth is expected to occur within 2 hours. The level of pain during the early phase can usually be managed with other strategies such as breathing techniques or diversion; giving an opioid early in labor may slow the process of labor. An opioid should be avoided in the 2 hours preceding birth; giving it to a client in the transition phase can cause respiratory depression in the newborn. Giving the medication when birth is imminent is contraindicated because it may cause respiratory depression in the newborn; the mother's level of consciousness will be altered as well, making it difficult for her to cooperate with requests for her to push.
Although a client in labor is prepared and plants to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol. Which phase of labor is the safest time for the nurse to administer this medication? a. early phase b. active phase c. transition phase d. expulsion phase
b. hypotension Regional anesthesia lowers blood pressure, which puts both mother and fetus in jeopardy. The client may not have the sensation to void, but the amount of urine manufactured does not decrease because a regional block does not affect the kidneys. Epidural anesthesia does not shorten the second stage of labor and does not cause uterine atony.
The nurse is caring for a client who has just received epidural anesthesia. The nurse will monitor for which adverse effects? a. uterine atony b. hypotension c. decreased urine production d. precipitous second stage of labor
b. an expected response to the process of labor and birth During the postpartum period, leukocytosis (WBC count of 15,000-20,000/mm3) is expected and related to the physical exertion experienced during labor and birth. A count of 17,000/mm3 does not constitute a drop in the WBC count, because the usual postpartum WBC count is between 15,000 and 20,000/mm3. WBC count normally increases after delivery. Because this is a normal response, it is not an indication of viral or bacterial infection.
Twenty-four hours after an uncomplicated labor and birth a client's complete blood count reveals a white blood cell (WBC) count of 17,000/mm3. How should the nurse this WBC count? a. a normal decrease in WBCs b. an expected response to the process of labor and birth c. a sign of an acute sexually transmitted viral infection d. a sign of a bacterial infection of the reproductive system
c. decreased blood pressure The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.
When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? a. diminished peripheral pulses b. unequal bilateral breath sounds c. decreased blood pressure d. increased oral temperature
d. turning the client on her side Maternal hypotension is a common complication of epidural anesthesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. If signs and symptoms do not abate after the client is turned on her side, the primary healthcare provider should be notified. Checking the vaginal area for bleeding is not an assessment specific to epidural anesthesia- it is part of the general nursing care during labor. Fetal heart rate monitoring is a continuous process, and the rate should be recorded every 15 mins.
During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction? a. notifying the primary healthcare provider b. checking the vaginal area for bleeding c. checking the fetal heart rate every 3 minutes d. turning the client on her side
b. floating presenting part A floating fetal head in a primigravida of 42 weeks gestation who is in early labor is suggestive of cephalopelvic disproportion, because engagement usually occurs 2-4 weeks before term in primigravidas. Rupture of membranes may put the client at risk for infection if it occurs more than 24 hours before admission, however the data do not indicate this. Some vaginal bleeding occurs during early labor when the presenting part bears down on the capillary structures of the cervix. The presence of fetal heart tones in the right lower quadrant is a reassuring sign of cephalic presentation.
A client is admitted to the birthing unit. The nurse reviews the client's history and assesses the fetal and maternal status. Which clinical finding alerts the nurse to a potential problem with a birth process? a. ruptured membranes b. floating presenting part c. streaks of blood from the vagina d. fetal heart tones in the right lower quadrant
c. infusing oxytocin by piggyback into the primary line Piggybacking the oxytocin allows it to be discontinued, if necessary, while permitting the vein to remain open by way of the primary IV line. Cervical dilation is checked when there is believed to be change, not on a regular basis. Unless specifically requested by the client, there is no reason to maintain a dark quiet labor environment. Although positioning the client on her left side is recommended, it is not the primary concern at this time; there are no data to indicate maternal hypotension.
A nurse assesses a primigravida who has been labor for 5 hours. The FHR tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin infusion is prescribed. What is the priority nursing intervention at this time? a. checking cervical dilation every hour b. keeping the labor environment dark and quiet c. infusing oxytocin by piggyback into the primary line d. positioning the client on the left side throughout the infusion
a. during the latent phase of the first stage of labor During the latent phase of the first stage of labor, the client is excited and open to learning. The contractions are not as strong as they are going to be, so the client has time between contractions to absorb the nurse's teaching. Contractions are more frequent and stronger in the active phase of the first stage. The increased frequency decreases the clients ability to absorb information. During the active phase of the second stage of labor the client will be bearing down to expel the fetus, and simple breathing techniques are not appropriate. During the transition phase of the first stage of labor the contractions are at their maximum intensity, which inhibits the client's ability to listen.
A primiparous client reports to the maternity unit stating that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes. A cervical assessment reveals that she is in true labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques? a. during the latent phase of the first stage of labor b. during the active phase of the first stage of labor c. during the active phase of the second stage of labor d. during the transition phase of the first stage of labor
a. maintaining IV fluid administration b. Having oxygen available in case of hypotension c. checking the bladder for distention every 2 hours e. monitor fetal heart rate and labor progress per hospital protocol Hypotension is a common problem in a client receiving epidural analgesia. IV fluids can help counter the problem and also provide a vehicle for emergency drug administration. Oxygen should be available incase of hypotension as a result of the epidural block or as emergency care should the anesthetic agent migrate upward. Because sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor; possibly resulting in trauma to the bladder. Fetal heart tones and the progress of labor should be monitored. The client should be positioned on her side to prevent vena cava syndrome. Labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.
A woman at 40 weeks gestation is admitted in active labor. When the client reaches 5 cm dilation, the woman asks for an receives epidural analgesia. Once the epidural catheter has been inserted, which assessments and interventions should be performed? Select all that apply. a. maintaining IV fluid administration b. Having oxygen available in case of hypotension c. checking the bladder for distention every 2 hours d. positioning the client supine for ease of monitoring e. monitor fetal heart rate and labor progress per hospital protocol f. administering an oxytocin infusion to maintain the labor pattern