PrepU 13, 14, 21 OB LABOR

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

second stage of labor Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal." In most term pregnancies the fetus presents head down. In a breech presentation, the fetal buttocks, feet, or both present to the birth canal. Transverse lie is the same as shoulder presentation.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5. A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used.

labor dystocia abnormal fetal heart rate tracing fetal malpresentation multiple gestation suspected macrosomia The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

A woman the nurse is caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. The nurse's best response would be that:

she needs to rest because her contractions are hypertonic. These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.

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 Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5.

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. In the hypoxic fetus, the pH will fall below 7.2, which is indicative of fetal distress.

contraction pattern every 15 minutes

Assess the contraction pattern every 15 minutes. The pattern will be similar to that found in the transition phase (i.e., contractions occur every two to three minutes, last 60 to 90 seconds, and are of strong intensity).

During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent, and the baseline FHR is within normal limits. What should the nurse do first?

Help the woman change positions. Changing positions is a first intervention to determine if this will improve the oxygen to the fetus. Supplemental oxygen should be maintained until the mother is stable. Placing the client on her side may increase the work of breathing. Pharmacological interventions are premature.

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?

Lie on her side so she is comfortable. The best position for all women during labor is on their side.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A client is in the first stage of labor, latent phase. Her membranes are intact, and her contractions are mild. Considering the client's condition and phase of labor, the nurse knows that which aid will facilitate labor?

ambulation ad lib To facilitate the first stage of labor, ambulation and movement will allow better fetal descent and help to speed the labor process. Bed rest will slow or stop the labor process. The client may use the bathroom as needed, but this does not affect labor rate. The client should remain mobile.

Which action could the nurse initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position?

Massage her lower back. Counterpressure against the woman's back by a support person can be helpful in reducing this type of pain.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth. Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth.

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal. Labor is slow. Dystocia is said to exist when the progress of labor deviates from normal and is slow.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask The client should be administered oxygen by mask because the abnormal FHR pattern could be due to inadequate oxygen reserves in the fetus. Because the client is in preterm labor, it is not advisable to apply vibroacoustic stimulation, tactile stimulation, or fetal scalp stimulation.

A client the nurse cares for in labor asks what causes labor to begin. Which statement is a possible explanation?

Prostaglandins may be the causative factor of labor. The cause of labor is unknown, but prostaglandin release is theoretically one of the possible causes for onset of labor. It is unknown whether progesterone, estrogen, or calcium have any effect on labor.

A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client?

The cervix takes around 12 to 16 hours to dilate during first pregnancy. The labor of a first-time-pregnant woman lasts longer because during the first pregnancy the cervix takes between 12 and 16 hours to dilate completely. The intensity of the Braxton Hicks contractions stays the same during the first and second pregnancies. Spontaneous rupture of membranes may occur before the onset of labor during each birth, not only during the first birth.

A patient who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed?

placenta previa Vaginal examinations should never be done if the woman presents with bright red painless bleeding until placenta previa is ruled out. The other options would not be concerns at this time based on the findings.

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

prolonged decelerations Prolonged decelerations are associated with prolonged cord compression, 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 nurse knows that a doula can be part of a laboring client's health care team. Which intervention would the nurse explain to the client is part of the doula's responsibility?

providing support and explanations during labor and birth A doula provides support, encouragement, comfort measures, and explanations of the process throughout labor and birth. The doula does not replace the partner/father or provide nursing tasks during the process.

A pregnant woman comes to the emergency department because she thinks she is in labor. The nurse determines that the client is in true labor when assessment of contractions reveals which finding?

radiating to the front of the abdomen from the back Contractions that begin in the back and then radiate to the front are typical of true labor. Contractions that slow when a woman walks or changes position suggest false labor, as do irregular contractions. Contractions lasting 30 seconds or less commonly suggest Braxton Hicks contractions and are associated with false labor.

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

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

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?

"You are still 2 cm dilated, but the cervix is thinning out nicely." Women are anxious to have frequent reports during labor, to reassure them everything is progressing well. If giving a progress report, the nurse should remember most women are aware of the word dilatation but not effacement. Therefore, just saying, "no further dilatation" is a depressing report. "You're not dilated a lot more, but a lot of thinning is happening, and that's just as important" is the same report given in a positive manner.

A woman asks the nurse if she can eat something during labor. Which response by the nurse would be best?

"You could have some hard candy to suck on." If women are kept NPO during labor, they can be administered anesthesia safely in an emergency. Stomach-emptying time is decreased.

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?

-2 When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?

0 Fetal engagement signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis. The fetus is said to be engaged in the pelvis when the presenting part reaches 0 station.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

What is the normally accepted fetal heart rate range?

110-160 bpm The standard acceptable fetal heart rate baseline is the range of 110-160 beats per minute. Sustained heart rates above or below the norm are cause for concern.

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips. For slow-paced breathing, the nurse should instruct the woman to inhale slowly through her nose and exhale through pursed lips. In shallow or modified-pace breathing, the woman should inhale and exhale through her mouth at a rate of 4 breaths every 5 seconds. In pattern-paced breathing, the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. Holding the breath for 5 seconds after every three breaths is not recommended in any of the three levels of patterned breathing.

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Hypertonic contractions cause uterine cell anoxia, which is painful.

What is the most important thing a nurse can do during labor and birth to prevent maternal and fetal infection?

Thoroughly wash the hands before and after client contact. The most important infection control technique in any health care setting is thoroughly washing hands on routine basis. Keeping the area clean is secondary, but is also important.

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?

Turn off the pitocin. Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

fetal heart tones. When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?

hospitalization, tocolytic therapy, and IM corticosteroids At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring and a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a postterm pregnancy.

The nurse is teaching a prenatal class the signs and symptoms of true labor. What is the appropriate response by the class that shows an understanding of true labor contractions?

increase even if I relax and take a shower True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.

The nurse is working with a client in labor. She is happy and cheerful and states she is "ready to see her baby." What stage or phase of labor would she anticipate the client to be in right now?

latent phase The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage two she may remain positive, but the work of labor is very intense.

A woman is documented on the labor and birth board to be 7 cm dilated. Her family wants to know how long she will be in labor. The nurse should provide which information to the family?

"She is in active labor; she is progressing at this point and we will keep you posted." At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.

A woman at 39 weeks gestation has been in labor for 8 hours and is asking how far she is dilated. She attended childbirth classes and is aware of the stages and phases of labor. She had a vaginal exam 30 minutes prior to her asking again. How should the nurse respond to her question?

"Your labor signs have not changed; we are looking for changes in your labor pattern before we check you again." "Your labor signs have not changed; we are looking for changes in your labor pattern before we check you again." The cervix must be assessed with a vaginal exam. The frequency of vaginal exams is based on the signs of changes in labor. The client has not demonstrated any changes in her labor pattern; the nurse should provide education on the reason for not checking her.

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle?

8 to 12 weeks The posterior fontanelle is a triangular-shaped area at the back of the skull. The nurse should inform the client that the posterior fontanelle normally closes by 8 to 12 weeks after birth, and if there is delay the primary health care provider should be notified.

A client in her third trimester of pregnancy arrives at a health care facility with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates that the client has edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next?

Continue to monitor the client. The nurse knows that the client is experiencing lightening. Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis and may occur 2 weeks or more before labor. The uterus lowers and moves into a more anterior position. The client may report increased respiratory capacity, decreased dyspnea, increased pelvic pressure, cramping, and low back pain. She may also note edema of the lower extremities as a result of the increased stasis of blood pooling, an increase in vaginal discharge, and more frequent urination. The nurse would continue to monitor the client as this is a normal progression of pregnancy.

A nursing student is learning about intermittent fetal heart rate monitoring during labor. The student correctly chooses which of the following as used routinely for this procedure? (Select all that apply.)

Doppler fetoscope fetal monitor Intermittent fetal heart rate ascultation uses fetoscope, Doppler, or fetal monitor. An intrauterine pressure catheter is inserted into a pocket of amniotic fluid and is a continuous internal monitoring of contractions.

A woman arrives in the labor and birth department and is panting and screaming "the baby is coming". What is the priority intervention by the nurse?

Quickly move the woman to a labor bed, and check the perineum. The woman is showing signs of advanced labor, possibly in transition or stage two. She needs to be managed as an imminent birth and taken directly to a room for vaginal assessment. Vital signs, medical/obstetrical history, and her room assignment can be taken care of later in the process.

When teaching a group of nursing students about uterine contractions, which of the following would the instructor include as a typical feature?

Retracting of the lower segment The nurse should identify retraction of the lower segment of the uterus as a feature of typical uterine contractions. As labor progresses the uterine contractions become stronger. The upper segment of the uterus contracts more actively than the lower segment. The lower segment retracts, pulling up the cervix. The upper segment thickens with time and the lower segment thins.

A pregnant woman calls her provider's office to report she thinks she is in labor. The client reports contractions have been fairly strong and at these times: 12:05, 12:10, 12:15, and 12:20. What information is gathered based on this data?

The frequency of the contractions is every 5 minutes. Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider.

The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?

The uterus contracts and squeezes the cord against the fetus. Cord compression is not continuous when variable decelerations are occurring. The compression occurs when the uterus contracts and squeezes the cord against the fetus. It is relieved when the uterus relaxes between contractions. Prematurity and fetal sleep will cause decreased or absent variabilty.

A postbirth complete blood count (CBC) has noted an elevated white blood cell (WBC) count of 22,000/mm3. Which rationale is accurate regarding the elevated WBC count?

This is a normal variation due to the stress of labor. An elevation of WBC up to 30,000mm/3 can be normal variation for any woman after birth. This is related to the stress on her body from labor and birth. Antibiotics are not indicated as this is a normal response to intense stress. The increase in WBC is not related to cesarean birth. Retesting would be wasteful as it is known that this is a normal response to any stress.

The nurse explains Leopold's 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 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.

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive assessment that uterine contractions are effective would be:

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

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?

every 15 minutes During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.

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 Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

increase in blood pressure increase in respiratory rate increase in heart rate

A woman is told she has an anthropoid pelvis. This means her pelvis:

is narrow transversely. A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis."

The five "Ps" of labor are:

passageway, passenger, position, powers, psych

A pregnant woman, multipara, has been in labor for several hours. She cries out that her contractions are getting harder and that she cannot do this. The client is really irritable, nauseated, annoyed, and fearful of being left alone. Considering the client's behavior, the nurse would expect the cervix to be dilated how many centimeters?

8 to 10 The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8-10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

A nurse is performing a physical assessment of a woman in labor. As part of her assessment, she examines the outer and inner surfaces of her lips. What is the best rationale for this assessment?

Detection of herpes virus infection Examine the outer and inner surfaces of her lips carefully to detect herpes lesions (pinpoint vesicles on an erythematous base). Report to her primary care provider if herpetic lesions are present anywhere because although oral lesions are invariably a type I herpes virus (common cold sores), type II (genital) herpes virus needs to be identified as this can be lethal to newborns; a woman primary health care provider may suggest the woman with oral herpes lesions take isolation precautions such as not kissing her newborn until the lesions crust. Be certain to palpate for enlargement of neck lymph nodes to detect the possibility of a respiratory infection. Inspect the mucous membrane of her mouth and the conjunctiva of her eyes for color to see if paleness suggests anemia. Auscultate the woman's lungs to be certain they are clear of rales.

A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor?

It helps to rotate fetus in a posterior position. The advantage of adopting a kneeling position during labor is that it helps to rotate the fetus in a posterior position. Facilitating vaginal examinations, facilitating external belt adjustment, and helping the woman in labor to save energy are advantages of the back-lying maternal position.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes. The nurse should turn the client on her left side to increase placental perfusion, administer oxygen by mask to increase fetal oxygenation, and assess the client for any underlying contributing causes. The client's questions should not be ignored; instead, the client should be reassured that interventions are to effect FHR pattern change. A reduced IV rate would decrease intravascular volume, affecting the FHR further.

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

allowing the woman time to be alone Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.

The initial descent of the fetus into the pelvis to zero station is which one of the cardinal movements of labor?

engagement The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.

A nurse is teaching a group of nursing students about the mechanism of labor when the fetus is in a cephalic presentation. Given in random order are a series of events that take place in a cascade to end with the birth of the baby. Arrange the series of events in the most likely sequence they occur. All options must be used.

flexion internal rotation extension restitution external rotation The sequence of normal mechanism of labor involves flexion, internal rotation, extension, restitution, and external rotation. Following descent, the baby's head encounters resistance and flexes so that the chin touches the chest. During internal rotation, the occiput is rotated 45° anteriorly so as to lie beneath the symphysis pubis. The baby's neck is twisted in internal rotation. Following internal rotation, the delivery of the head is by extension. Once the head is born by extension, there is external rotation, in which it turns 45° more so that the shoulders lie anterior posteriorly.

The labor and delivery nurse knows that internal monitoring during labor is an invasive technique. She correctly identifies an increase in the risk of which of the following for both mother and fetus if this is done?

infection Because internal monitoring techniques are invasive, both the woman and the fetus can become ill with infection. Internal methods should be used only when the benefit clearly outweighs the risk.

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient?

latent phase Contractions during the latent phase of labor are typically 5 to 10 minutes apart and last 30 to 45 seconds. The cervix is dilated 1 to 3 cm, and effacement begins.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?

restoration of blood flow to uterus and placenta The pauses between contractions during labor are important because they allow the restoration of blood flow to the uterus and the placenta. Shortening of the upper uterine segment, reduction in length of the cervical canal, and effacement and dilation of the cervix are other processes that occur during uterine contractions.

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 Signs that the placenta is separating including 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.

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations. Second-stage contractions are so unusual that most women are unable to think of things other than what is happening inside their body.

The nurse should initially implement which intervention when a nulliparous woman telephones the hospital to report that she is in labor?

Ask the woman to describe why she believes that she is in labor. The nurse needs further information to assist in determining if the woman is in true or false labor. She will need to ask the client questions to seek further assessment and triage information. Having her wait until membranes rupture may be dangerous, as she may give birth before reaching the hospital. She should continue fluid intake until it is determined whether or not she is in labor. She may be in false labor, and more information should be obtained before she is brought to the hospital.

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?

Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.

The nurse is assessing a woman in active labor. She notes a small mass above the symphysis pubis, rounded, distended, and nontender. What intervention should the nurse take next?

Check the chart for the last void. The most probable explanation of the mass is the bladder, which is full. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be taken care of by the nurse. The client would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor?

These contractions help in softening and ripening the cervix. Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.

A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure?

To prevent supine hypotension syndrome The term "rhythm strip testing" means assessment of the fetal heart rate for whether a good baseline rate and long- and short-term variability are present. For this, help a woman into a semi-Fowler's position (either in a comfortable lounge chair or on an examining table or bed with an elevated backrest) to prevent her uterus from compressing the vena cava and causing supine hypotension syndrome during the test. Placing her in this position does not decrease the heart rate of the fetus. It is not done to aid the woman as she pushes in labor, as she is not in labor yet. It is not done to prevent her from falling out of bed.

The expected fetal heart rate response in an active fetus is:

acceleration of at least 15 bpm for 15 seconds. A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?

acme The acme is the peak intensity of a contraction. The increment refers to the building up of the contraction. The decrement refers to the letting down of the contraction. Diastole refers to the relaxation phase of a contraction.

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which compounds is the nurse referring to in the explanation?

catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

cervical dilation The primary change occurring during the first stage of labor is progressive cervical dilation. Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?

dilation of cervix diameter to 10 cm The first stage of labor terminates with the dilation of the cervix diameter to 10 cm. Diffused abdominal cramping and rupturing of the fetal membrane occurs during the first stage of labor. Regular contractions occur at the beginning of the latent phase of the first stage; they do not mark the end of the first stage of labor.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilatation refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

external electronic fetal monitoring Analysis of the FHR using external electronic fetal monitoring is one of the primary evaluation tools used to determine fetal oxygen status indirectly. Fetal pulse oximetry measures fetal oxygen saturation directly and in real time. It is used with electronic fetal monitoring as an adjunct method of assessment when the FHR pattern is abnormal or inconclusive. Fetal scalp blood is obtained to measure the pH. The fetal position can be determined through ultrasonography or abdominal palpation but is not indicative of fetal oxygenation.

During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions?

felt first in lower back and sweep around to the abdomen in a wave begin irregularly but become regular and predictable increase in duration, frequency, and intensity True contractions begin irregularly but become regular and predictable; are felt first in the lower back and sweep around to the abdomen in a wave; continue no matter what the woman's level of activity; increase in duration, frequency, and intensity; and achieve cervical dilatation. False (Braxton Hicks) contractions begin and remain irregular; are felt first abdominally and remain confined to the abdomen and groin; often disappear with ambulation or sleep; do not increase in duration, frequency, or intensity; and do not achieve cervical dilatation.

A pregnant client in her 32nd week of gestation has been admitted to a health care center reporting decreased fetal movement. What should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds?

fetal back The nurse assessing the client should first determine the fetal back before placing the fetoscope on the client's abdomen. The fetal back is determined first because it is through the back that the heart signals are best transmitted. During labor, the fetal heart rate should be assessed to check for any variations indicating distress. Fetal heart rate is auscultated by placing a fetoscope on the client's abdomen in the area of the fetal back. Determining the fetal head, shoulders, and the buttocks would be of no help in localizing the heart sounds.

A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor?

first, active Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor, which is characterized by cervical dilation of 4 to 7 cm. Regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and at -1 station. Second stage of labor begins when the cervix is 10 cm dilated. The first latent phase is characterized by the onset of regular contractions and cervical dilation of 0 to 4 cm. Third stage of labor is from birth of the infant to completed delivery of the placenta.

A new OB/GYN care provider has just finished evaluating her one hundredth client. In reviewing the documentation from all clients thus far, which types of pelvis would the nurse assume the care provider has seen the most and the least?

gynecoid and platypelloid, respectively The gynecoid is the typical female pelvis shape; platypelloid pelvis is the least common type of pelvis in women. Women with anthropoid pelvic shapes are able to give birth normally one third of the time and are somewhat rare. An android pelvis is similar to a male pelvis and is seen in 16% of nonwhite women.

A nurse is caring for a pregnant client with rhythmic uterine contractions. Which feature should the nurse identify as associated with true labor?

increase in frequency of the contractions The nurse should identify that there is an increase in the duration of the contractions associated with true labor. In true labor, the duration, frequency, and intensity of uterine contractions increase. Position change does not reduce the uterine contractions. In false labor, the uterine contractions often disappear with ambulation and sleep. Also, there is no increase in frequency, duration, or intensity of the contractions, and the cervix fails to dilate any further.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

increase in heart rate increase in blood pressure increase in respiratory rate When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

increased white blood cell count The nurse should identify increased white blood cell count as the hematological change occurring in a client during labor. The increase in the white blood cell count can be attributed to physical and emotional stress during labor. During labor there could be a decrease, and not increase, in the blood coagulation time. There is an increased, and not a decreased, plasma fibrinogen level during labor. Blood glucose levels are decreased during labor.

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.

intensity of contractions frequency of contractions uterine resting tone The nurse should assess the frequency of contractions, intensity of contractions, and uterine resting tone to monitor uterine contractions. Monitoring changes in temperature and blood pressure is part of the general physical examination and does not help to monitor uterine contraction.

Place the following stages of labor in order from what occurs first to last. All options must be used.

latent stage active stage transition stage second stage third stage The latent stage is the beginning of labor from approximately 0 cm dilated to 3 to 4 cm dilated. The active stage is from when the cervix is 4 cm dilated to 8 cm dilated. Active labor begins to become more uncomfortable for the client, and the contractions are usually stronger, longer, and closer together. Transition is approximately 8 to 10 cm. The second stage of labor is from when the client is 10 cm dilated to birth of the baby. The third stage of labor is from the birth of the baby to the delivery of the placenta.

The student nurse is preparing to assess the fetal heart rate (FHR). She 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 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.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

lie The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to longitudinal. Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship of the different fetal parts to one another. Position is the relationship of the fetal denominator to the different sides of the maternal pelvis.

After teaching a pregnant client who is in her last weeks of pregnancy about the signs and symptoms of approaching labor, which signs or symptoms if identified by the client would indicate effective teaching? Select all that apply.

lightening bloody show backache The signs of approaching labor include lightening, bloody show, and backache. Lightening is the falling forward of the pregnant uterus due to settlement of the fetal head into the maternal pelvis. Backache associated with pelvic cramping pain, which is regular and increases in the intensity, is suggestive of impending labor. Bloody show is the expulsion of the cervical mucus plug tinged with blood, and occurs due to cervical effacement and dilatation. Weight loss and diarrhea are other signs of impending labor. Weight gain and constipation are not signs of impending labor.

The nurse notes that a client's amniotic fluid is green when the membranes rupture. What finding would the nurse document?

meconium in the amniotic sac 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. Umbilical cord prolapse occurs when pressure on the cord stops the flow of oxygen to the fetus. Amniotic embolism results when amniotic fluid enters circulation.

The skull is the most important factor in relation to the labor and birth process. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

molding The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull thereby reducing the diameter of the head.

A 37-year-old woman in the final weeks of her first pregnancy visits the health care provider's office for a scheduled check-up. What might a nurse note as a sign of labor in speaking with the woman prior to the examination?

nesting Nesting is the activity or burst of energy women often experience prior to the onset of labor. The client could express this in her words or by what her activities had been at home. Dilation, effacement, and cervical ripening are all observable by the provider on exam.

A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?

pain from the dilation or stretching of the cervix In the first stage of labor, the primary source of pain is the dilation of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor.

When educating a group of nursing students about the different types of pelvis, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type?

platypelloid Platypelloid pelvis is a flat pelvis with a wider transverse diameter than anterior-posterior diameter, ischial spines are wide apart, and the sacrum is short. In a gynecoid pelvis, the inlet is oval, the pubic arch is wide, it has dull ischial spines, and the sacrum has no anterior or posterior inclinations. In an android pelvis, the inlet is heart shaped, the ischial spines are prominent, and the sacrum is straight. In an anthropoid pelvis, the anterior-posterior diameter is longer than the transverse diameter, ischial spine is somewhat prominent, and the sacrum is inclined posteriorly.

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding?

poorly ossified cranial vault Molding is an adaptive process in which there is overriding and movement of the bones of the cranial vault to adapt to the maternal pelvis. The poorly ossified bones of the cranial vault, along with loosely attached membranous attachments, allow for the process of molding in the fetal skull. The bones of the face and the base of the skull are completely ossified and united. Hence they cannot allow for movement or overriding. The membranous attachments are loosely bound to the cranial vault and not tightly, which allows for molding of the fetal skull.

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?

tachycardia and a falling blood pressure Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs.

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?

third Stage three begins with the birth of the baby and ends with delivery of the placenta.

A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? (Select all that apply.)

transition active latent The first stage of labor includes three phases: latent, active, and transition.

A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor?

transition phase The woman is likely in transitional labor (first stage, transition phase) as evidenced by her increasing anxiety and distress, intense frequent contractions, and cervical dilation of 9 cm. The amount of bloody show indicates remarkable cervical changes. Cervical dilation in the transition phase is 8 to 10 cm. The latent and early phase is the same phase of labor in the first stage and characterized by positive coping, mild contractions, and cervical dilation of 1 to 4 cm. The active phase is characterized by increased anxiety but cervical dilation of 4 to 7 cm.

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain." Effleurage is a light abdominal massage used to keep the laboring woman's focus on the massage instead of the pain of labor.

A client is 32 weeks pregnant and sent home on modified bedrest for preterm labor. She is on tocolytics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse?

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." The client needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider says it is safe.

A client is having a routine prenatal visit and asks the nurse what the birth education teacher meant when she used the term zero station. What is the best response by the nurse?

"The presenting part is at the true pelvis and is engaged." Zero station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.

A client is in the active phase of labor. She is a low-risk client. The nurse evaluates the fetal monitor strip at 10:00 a.m. Moderate variability is present. The FHR is in the 130s with occasional accelerations, no decelerations. At what time does the nurse need to reevaluate the FHR?

10:30 a.m. Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns. Variability should be present, except for brief periods of fetal sleep or when the mother receives narcotics or other selected medications, and no late decelerations should be present. Accelerations of the FHR are normal.

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's planning of nursing care?

A woman may spend time thinking about what is happening to her. Women need a support person with them during all stages of labor.

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess amount of cervical dilation. If vaginal bleeding is absent during admission assessment, the nurse should perform vaginal examination to assess the amount of cervical dilation. Hydration status is monitored as part of the physical examination. A urine specimen is obtained for urinalysis to obtain a baseline. Vital signs are monitored frequently throughout the maternal assessment.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

Assess fetal heart rate for fetal safety. Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness. When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing intervention?

Change the position of the client. Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

Continue to massage the client's fundus. The nurse should monitor the client for uterine relaxation. If this is noted, the nurse would continually massage the client's fundus until it no longer felt boggy.

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?

Convert the birthing room to birth readiness before full dilatation is obtained Both grand multiparas (women who have given birth five or more times) and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled surrounding. As the client is likely to give birth relatively quickly, there is no need for oxytocin or to darken the room lights. There is also no indication that cesarean birth will be necessary, particularly because all of the client's previous births were vaginal.

A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process?

Initiate the technique only when the client is in active labor. The recommendation for initiating hydrotherapy is that women be in active labor (>5 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation. Women are encouraged to stay in the bath or shower as long as they feel they are comfortable. The water temperature should not exceed body temperature. The woman's membranes can be intact or ruptured.

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?

Long axis of fetus is perpendicular to that of client. If the long axis of the fetus is perpendicular to that of the mother, then the client's fetus is in the transverse lie position. If the long axis of the fetus is parallel to that of the mother, the client's fetus is in the longitudinal lie position. The long axis of the fetus being at 45° or 60° to that of the client does not indicate any specific position of the fetus.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRobert's maneuver The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?

Provide ongoing communication about what is happening. Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.

A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply.

Provide the client clear information on procedures involved. Encourage the client to have a sense of mastery and self-control. Encourage the client to have a positive reaction to pregnancy. To ensure a positive birth experience for the client, the nurse should provide the client clear information on procedures involved, encourage the client to have a sense of mastery and self-control, and encourage the client to have a positive reaction to pregnancy. Instructing the client to spend some time alone is not an appropriate intervention; instead, the nurse should instruct the client to obtain positive support and avoid being alone. The client does not need to change the home environment; this does not ensure a positive birth experience.

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen, and nutrients are cut off to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA The nurse should document the fetal position in the clinical record using abbreviations. The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter or abbreviation indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. The nurse's institution has a policy of taking photographs of such fetuses once they are born. The nurse informs the woman that pictures have been taken and asks her if she wants them; she angrily tells the nurse no, then bursts into tears. How should the nurse respond?

Tell her that the hospital will keep the photos for her in case she changes her mind. Emotional care of the woman is complex. The woman may need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the delivery. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

Labor can be indicated by which occurrence?

The client reports back pain, and the cervix is effacing and dilating. True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.

Which signs signify that the second stage of labor has begun?

The urge to push occurs. Second stage of labor is the pushing stage; this is typically identified by the woman's urge to push or a feeling of needing to have a bowel movement. The emotional state may be altered due to pain and pressure. Contraction frequency is variable and not clearly indicative of a particular stage. The fetus can be at stage -1 for any length of time.

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.

The nurse is assisting with the birth of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to emerge, but instead of continuing to emerge, it retracts into the vagina. What should the nurse try first?

Use McRobert's maneuver. This intervention is used with a large baby who may have shoulder dystocia and require assistance. The legs are sharply flexed, by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli's maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

A woman whose fetus in in the occiput-posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain?

applying counter pressure to the back Counter pressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:

assess the rate of flow of the oxytocin infusion. A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

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. The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

Which intervention has been demonstrated to reduce the release of catecholamines and anxiety, and has resulted in better birth outcomes for women?

continuous labor support Continuous labor support has been demonstrated to result in better labor outcomes in the current research. Continuous labor support is defined as caring for the labor patient by a nurse, doula, or primary support person who does not leave the client. Massage therapy is effective in that it engages gate control. Pharmacological interventions are useful but pose potential side effects to the mother and fetus. Hypnosis is less well understood.

A client is now in the second stage of labor. While doing the assessment, the nurse would gather what data at this time?

contraction pattern every 15 minutes Assess the contraction pattern every 15 minutes. The pattern will be similar to that found in the transition phase (i.e., contractions occur every two to three minutes, last 60 to 90 seconds, and are of strong intensity).

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?

contractions most forceful in the middle of uterus rather than the fundus Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.

A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression Oligohydramnios and meconium staining of the amniotic fluid are common complications of postterm pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s Assessing deep tendon reflexes hourly in a client receiving magnesium sulfate is appropriate as depressed DTRs are a sign of magnesium toxicity. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Assessing for depressed respiration and hypotension not tachypnea or tachycardia would be appropriate assessments needed for the safe administration of magnesium sulfate.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.

dull low backache malodorous vaginal discharge dysuria Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour.

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?

endorphins The nurse is referring to the release of endorphins, which are natural analgesic substances released by the movement of the client on the birth ball. The nurse should encourage the client to rock or sit on the birth ball. This causes the release of endorphins. The client's movement on the birth ball does not produce prostaglandins, progesterone, or relaxin. Prostaglandins are local hormones that bring about smooth muscle contractions in the uterus. Progesterone is a hormone involved in maintaining pregnancy. Relaxin is a hormone that causes backache during pregnancy by acting on the pelvic joints.

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

every 15 to 30 minutes During the active phase of labor, FHR is monitored every 15 to 30 minutes. FHR is assessed every 30 to 60 minutes during the latent phase of labor. 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, every 15 to 30 minutes during the active phase, and every 15 minutes during transition.

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version External version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor. The earlier baseline FHR was 140. The FHR now is 168. The nurse knows that which factors can affect changes in the FHR? Select all that apply.

fetal movement fetal distress maternal fever An increase in the FHR from baseline can mean that there is some type of fetal distress. This can happen with a maternal fever also. Narcotics may affect the heart rate variability but not the baseline FHR. Fetal movement can cause an increase in FHR, and utero-placental insufficiency can cause late decelerations in the FHR.

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client?

general anesthesia General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births.

A client is being admitted to labor and birth. When admitting an obstetric client in early labor, the first intervention by the nurse is:

good rapport is established with the client and significant other. On admission the client and her family need to establish a rapport with their caregiver. If the client is stable and there is no immediate need, rapport should be established over actions that can be taken care of later.

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours Precipitous labor is completed in less than 3 hours.

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 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 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes or the possibility of preeclamsia.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding. Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released.

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).

A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? Select all that apply.

spinal abnormality hypovolemia coagulation defects The nurse should check for any abnormality of the spine, hypovolemia, or coagulation defects in the client. An epidural is contraindicated in women with these conditions. Varicose veins and skin rashes or bruises are not contraindications for an epidural block. They are contraindications for massage used for pain relief during labor.

A woman presents in advanced labor, and birth appears imminent. What is the most important and appropriate aspect of admission for this woman?

taking her blood pressure and determining whether clonus or edema is present In advanced labor the most important assessments must be completed first. The assessment for signs or symptoms of preeclampsia must be assessed first. The history can be obtained after the birth of the baby or if labor slows down. Plans for the newborn can be figured out later. Blood tests can be run as soon as a sample can be taken from the mother.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

transverse lie A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

uterine rupture The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:

uteroplacental insufficiency. Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.