Uncomplicated Pregnancy, Labor & Childbirth

What is the optimal nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?

Assist the client's coach in helping her with the use of breathing techniques The client is in the early part of the first stage of labor, and it is important to help the partner with the role of coach. It is not necessary to check the fetal heart rate every 5 minutes until the second stage of labor. The first stage of labor is not as stressful for the fetus as the second stage of labor. Birth is not imminent at this time; the client is only dilated 4 cm. Suggesting that there is discomfort may increase anxiety and produce greater discomfort.

Five minutes after a birth the nurse determines that the client's placenta is separating. Which clinical finding indicates placental separation?

Umbilical cord lengthens As the placenta separates and descends down the uterus, the cord descends down the vaginal canal and therefore appears to lengthen. The fundus contracts and becomes rounded and firmer. The client may feel a contraction; however, it is not as uncomfortable as the painful contractions at the end of the first stage of labor. Continual seepage occurs in the presence of hemorrhage; a sudden large gush of blood heralds placental separation.

A primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the what?

Anterior pituitary gland Hypersecretion of melanocyte-stimulating hormone (MSH) from the anterior pituitary gland causes darkened pigmentations during pregnancy. MSH is not secreted by the adrenal glands, thyroid gland, or posterior pituitary gland.

During an emergency birth the fetal head is crowning on the perineum. How should the nurse support the head as it is being delivered?

By distributing the fingers evenly around the head Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from "popping out," which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate.

The nurse explains to a woman in her twenty-fourth week of pregnancy that absorption of medications taken orally during pregnancy may be altered as a result of what?

Delayed gastrointestinal emptying Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and of the intestines laterally and posteriorly; absorption of some medications, vitamins, and minerals may be increased. The glomerular filtration rate increases during pregnancy and is unrelated to the absorption of medications. Developing fetal-placental circulation is unrelated to the absorption of medications. The amount of gastric secretion is somewhat lower in the first and second trimesters but increases dramatically in the third trimester; neither decreased nor increased gastric secretions affect medication absorption.

A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement?

Encourage the family to bring in special foods preferred in their culture. In family-centered childbearing, care should be adapted to the client's cultural needs and preferences whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility but will not address the client's preferences. Ordering a high-protein milkshake as a between-meal snack may offer the client an option but is unlikely to meet the cultural preferences. Having the dietitian assist with planning meals does not address the underlying problem.

During her first prenatal visit the client reports that her last menstrual period began on April 15. According to Nägele rule, what is the expected date of delivery (EDD)?

January 22 To determine EDD with the use of Nägele rule, subtract 3 months from the date of the last menstrual period and add 7 days. January 8 is 2 weeks too early according to this formula. February 8 is too late. February 22 would be 1 month past the true EDD.

A pregnant client is scheduled for ultrasonography at the end of her first trimester. What should the nurse instruct her to do in preparation for the sonogram?

Increase fluid intake for 1 hour before the procedure In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation.

The nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond?

"During the eighth week of the pregnancy" During the eighth week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the second week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.

While the nurse is caring for a client in active labor whose fetus is at station 0, the client's membranes rupture spontaneously. The nurse determines that the fluid is clear and odorless. What should the nurse do next?

Assess the fetal heart rate (FHR) The FHR will reflect how the fetus tolerated the rupture of the membranes; if there is compression of the cord, it will be reflected in a change in the FHR. Although the client's comfort is important, it is not the priority. Although the practitioner should be notified, it is not the priority. Blood pressure is not influenced by rupture of the membranes.

A client is admitted to the birthing room in active labor. The nurse determines that the fetus is in the left occiput posterior (LOP) position. At which point can the fetal heart be heard?

Fetal heart sounds are heard through the fetus's back. When the position of the fetus is in the left occiput posterior (LOP) or left occiput anterior (LOA) position, fetal heart sounds are heard in the left lower quadrant of the mother. The fetus is in the right sacrum anterior (RSA) position if the fetal heart tones are heard in this area (a). The fetus is in the left sacrum anterior (LSA) position if the fetal heart tones are heard in this area (b). The fetus is in the right occiput posterior (ROP) position if the fetal heart tones are heard in this area (c).

What is the desired outcome for the intrapartum client during the third stage of labor?

Firmly contracted uterine fundus The third stage of labor spans the time from the birth of the baby to the delivery of the placenta; a firmly contracted uterus is desired because it minimizes blood loss. Providing comfort is a desirable goal, but is secondary to the life-threatening possibility of hemorrhage associated with a boggy uterus. Efficient fetal heart beat-to-beat variability is a concern in the first and second stages of labor; it is no longer applicable after the fetus is born. The maternal respiratory rate may vary above or below this range.

The nurse is caring for a client in active labor at a birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. In which stage of labor is this client?

First The client is in the first stage of labor because she is fully effaced but not yet completely dilated. The first stage lasts from the onset of contractions until full cervical effacement and dilation. The second stage of labor lasts from complete dilation to birth. Latent and transition are phases and not stages of labor. Latent is the first phase of the first and second stages of labor. Transition is the last of three phases occurring in the first stage of labor.

The nurse manager receives a report on the following laboring clients. Which client should the nurse see first?

G6 P5 with intact membranes at 5 cm of dilation A grand multipara (five or more births) is at greater risk for a precipitate labor and should be monitored more closely than a client with fewer deliveries and no other major risk factors.

After being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. During the assessment the nurse notes that the fetus's head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder?

Gently guiding the head downward After the newborn's head has rotated externally, the nurse gently guides the head downward for the birth of the anterior shoulder. Gradually flexing the head toward the mother's thigh, gently putting pressure on the head by pulling upward, and gradually extending the head above the mother's symphysis pubis are all contraindicated.

A client who has been breastfeeding tells the nurse on the third postpartum day that her breasts are painful and that she is afraid that the baby will hurt her while grasping the nipple and suckling. How should the nurse respond at this time?

Helping the client express some milk manually before feeding The pressure and tenderness resulting from accumulated milk can be relieved by manually expressing some of the fluid before feeding. Pain medication may be offered if other measures are unsuccessful; however, medication can be transferred to the infant through breast milk. Also, giving medication is a dependent function of the nurse that requires a prescription. The mother should not limit fluids, especially if she is breastfeeding. Breastfeeding, not formula feeding, should continue as a means of limiting engorgement and aiding milk production.

The fetus of a client in labor is found to be at +1 station. Where would the nurse locate the fetus's head?

Just below the ischial spines The term station is used to indicate the location of the presenting part. The level of the tip of the ischial spines is considered zero station. The position of the bony prominence of the fetal head is described in centimeters, minus (above the spines) or plus (below the spines). On the perineum, referred to as crowning, is designated as +5. High in the pelvis is indicated by the term floating, which means that the presenting part has not yet engaged in the pelvis. A station of -1 indicates that the head is just above the ischial spines.

Examination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document?

ROA, 0 station The fetal heart is in the right quadrant; therefore the fetus's head and back are on the right side. The head is engaged and is at 0 station. In the left occiput posterior (LOP) position, -2 station, the fetal heart should be heard on the left side; at station -2, the head is mobile. The information states that the head is anterior and flexed; at -3 station, the head is mobile. In the left occiput anterior (LOA) position, +1 station, the fetal heart should be heard on the left side; at +1 station, the head is engaged below the ischial spines.

The nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect?

Rectal pressure during contractions Rectal pressure occurs at the beginning of the transition phase of labor when the fetal head starts to press on the rectum during contractions. The perineum bulges when transition is complete and the cervix is fully dilated. Pink vaginal discharge occurs when labor begins, not at the beginning of the transition phase. The fetal head crowns at the end of the second stage, shortly before birth.

As the nurse inspects the perineum of a client who is in active labor, the client suddenly turns pale and states that she feels as if she is going to faint even though she is lying flat on her back. What is the nurse's priority intervention?

Turn her on her left side The client is experiencing supine hypotension, which is caused by compression of the large vessels by the gravid uterus. A side-lying position will relieve the pressure on the vessels, increase venous return, improve cardiac output, and increase blood pressure. Raising the head of the bed will not relieve uterine compression of the large vessels. Elevating the feet will not relieve uterine compression of the large vessels. Oxygen administration will not relieve uterine compression of the large vessels.

Why should the nurse limit food and oral fluids as a laboring client approaches the second stage of labor?

Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia. Gastric peristalsis often ceases during periods of stress. Abdominal contractions put pressure on the stomach and can cause nausea and vomiting, increasing the risk for aspiration. Although it is true that the increased acid secretion during the gastric phase may cause dyspepsia, it is not the reason for withholding food and oral fluids during labor; the primary reason for withholding it is the prevention of aspiration. Gastric peristalsis is decreased, not increased, during the stress of labor and birth.

The postpartum nurse is delegating tasks to an unlicensed health care worker. Which task should the nurse delegate?

Vital signs on a client 4 hours after delivery Evaluating the client's lochia, assessing the client's episiotomy, and helping the client breastfeed for the first time would involve assessment, teaching, or evaluation and should not be delegated. The only task that does not require any of these is taking vital signs 4 hours after delivery.

After reading that nutrition during pregnancy is important for optimal growth and development of the baby, a pregnant woman asks the nurse what foods she should be eating. The nurse begins the teaching/learning process by doing what

Asking the client what she usually eats at each meal Successful dietary teaching should incorporate the client's food preferences and dietary patterns. Spicy foods are permissible if the client does not experience discomfort after eating them. Instructing the client to add calories while continuing to eat a healthy diet presupposes that the client has been eating a healthy diet. It does not provide for the additional protein requirements of pregnancy. Providing the client with a list of foods for reference when planning meals does not take into consideration the client's likes and dislikes or cultural preferences.

A nurse performs Leopold's maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in pubic area; and cephalic prominence on right side. Applying these findings, which fetal position does the nurse identify?

Left occipitoanterior (LOA) In the LOA position, the small parts are on the right, the smooth back is on the left, and the head is in the pelvis. The LSP position is a breech position, and therefore the fetal head will not be in the pelvic area; the data reveal a hard, round, movable object in the pubic area, which indicates that the fetus is in the vertex position. The RSP position is a breech position, and therefore the fetal head will not be in the pelvic area. In the ROA position, the small parts will be on the left and the smooth back on the right.

The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping due to afterbirth pains?

Multipara who has vaginally delivered three children A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.

The nurse is admitting a client in active labor. When the fetal monitor is applied to the client's abdomen, it records late decelerations. What should the nurse do first?

Reposition her on her left side Late decelerations may indicate impaired placental profusion. Turning the client on her left side relieves pressure on the vena cava and aorta, improving circulation to the placenta. Calling the practitioner is premature. The nurse should notify the practitioner if late decelerations continue after nursing interventions are implemented. Elevating the head of the bed will increase pressure on the vena cava and aorta, further reducing placental perfusion. Oxygen may be administered if placing the client on her left side does not resolve the late decelerations.

The nurse is caring for a primigravid client during labor. Which physiologic finding does the nurse observe that indicates birth is about to take place?

The perineum has begun to bulge with each contraction The bulging perineum indicates that the fetal head is on the pelvic floor and birth is imminent. An increase in bloody show and an increasingly irritable client are seen during the transition phase or at the beginning of the second stage. Contractions occurring more frequently that are stronger and last longer are part of the progress of labor, not a sign that birth is imminent.

The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious and asks a nurse, "Would it be best for me to leave, since I don't seem to be doing my wife much good?" What is the appropriate response by the nurse?

"I know that this is hard for you. Let me try to help you coach her during this difficult phase." Both the father and the mother need additional support during the transition phase of the first stage of labor. Telling the father not to run out on his wife is judgmental; it suggests that the father will be failing his wife by leaving. The husband should be present throughout labor to support his wife, and he should be assisted in this role. Telling the father to sit in the waiting room does not encourage the husband to fulfill his role of supporting his wife during labor.

After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond?

"I'll get you some warm blankets to help make the chill go away." A postpartum chill is an expected vasomotor reaction. Covering the client with warm blankets will ease the discomfort. Taking the client's temperature, palpating the uterus, and monitoring the lochial flow are all parts of the routine postpartum assessment; however, they do not need to be done in response to the sensation of a chill.

Epidural anesthesia was initiated 30 minutes ago for a client in labor. The nurse determines that the fetus is experiencing late decelerations. List the following nursing actions in order of priority.

1.Reposition client on her side. 2.Increase intravenous fluids. 3.Reassess the fetal heart rate (FHR) pattern. 4.Notify the healthcare provider if late decelerations persist. 5.Document interventions and related maternal/fetal responses. Repositioning the client to the side increases uterine blood flow, improves cardiac output, and takes the pressure exerted by the uterus off the vena cava. Increasing the delivery of fluids augments uterine blood flow and improves cardiac output. Reassessing the FHR pattern enables the nurse to determine whether the FHR has returned to a safe level without reflex late decelerations. Persistent late decelerations are a nonreassuring fetal sign; the healthcare provider should be informed. Documentation of interventions and client responses ensures that information is included in the client's legal clinical record and communicated to other care providers.

A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus to be where?

Even with the umbilicus Around the 22nd week of gestation the top of the fundus is at the level of the umbilicus. Just above the symphysis pubis is too low for a pregnancy between the fifth and sixth months of gestation. Two fingerbreadths above the umbilicus is too high for 20 to 22 weeks' gestation. Halfway between the symphysis pubis and umbilicus is too low for a pregnancy between the fifth and sixth months of gestation.

While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?

G5 T1 P1 A2 L2 The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had one term (T) pregnancy (one that lasts 40 weeks plus or minus 2 weeks): the 41-week pregnancy. The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions.

The membranes of a client who is at 39 weeks' gestation have ruptured spontaneously. Examination in the emergency department reveals that her cervix is dilated 4 cm and 75% effaced, and the fetal heart rate is 136 beats/min. She and her partner are admitted to the birthing unit. What is the nurse's primary intervention upon the client's arrival to the unit?

Introduce the staff nurses to the couple and try to make them feel welcome The client is in the first stage of labor; she and the fetus were assessed earlier, and both are stable. At this time the priority of care is the establishment of a trusting relationship with the client and her partner. This will help allay their anxiety. Putting the client in bed and attaching an external fetal monitor may be necessary later; however, it is not the priority. The history should be taken from the client as long as she is capable of providing it. Asking the couple to wait in the examining room while notifying the healthcare provider is not a priority; the provider may have been notified already.

What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?

Moderate serosa The uterus sloughs off the blood, tissue, and mucus of the endometrium post-delivery. This happens in three stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the first and heaviest stage of lochia. The blood that's expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for the first three days following delivery. Lochia serosa is the second stage of postpartum bleeding and is thinner in consistency and brownish or pink in color. Lochia serosa typically lasts from day four through day 10, following delivery. Lochia alba is the final stage of lochia. Rather than blood, there will be a white or yellowish discharge that's generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around six weeks after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than ten days.

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does this test do?" The nurse responds that this test can reveal what?

Nerual tube defects The alpha-fetoprotein test can detect not only neural tube defects, but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the alpha-fetoprotein test.

List the mechanisms of labor in the correct sequence. Flexion Engagement Descent External rotation Extension Internal rotation Expulsion

The cardinal movements of the mechanism of labor that occur in a vertex presentation are: (1) Descent of the fetal presenting part through the true pelvis. (2) Engagement of the fetal presenting part as its widest diameter reaches the level of the ischial spines of the mother's pelvis. (3) Flexion of the fetal head so that the smallest head diameters pass through the pelvis. (4) Internal rotation to allow the largest fetal head diameters to match the largest maternal pelvic diameters. (5) Extension of the fetal head as it passes beneath the mother's symphysis pubis. (6) External rotation of the fetal head to allow the shoulders to rotate internally to fit the mother's pelvis. (7) Expulsion of the fetal shoulders and fetal body.