Unit 2 Intrapartum Nursing Care

A nurse is caring for a client who is in labor and is experiencing late decelerations in the FHR. Which of the following actions should the nurse take first? A. Assisting the client into the left-lateral position. B. Apply oxygen at 10L/min via a nonrebreather face mask. C. Increase the rate of the maintenance IV fluid. D. Prepare the client for a vaginal exam.

A. Assisting the client into the left-lateral position. The greatest risk to the fetus during late decelerations is uteroplacental insufficiency.

A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the nurse take first? A. Check the amniotic fluid for meconium. B. Monitor FHR for distress. C. Dry the client and make her comfortable. D. Monitor uterine contractions.

B. Monitor FHR for distress. The greatest risk to the client and fetus is umbilical cord prolapse, leading to fetal distress following rupture of membranes. The first action by the nurse is to monitor the fetal heart rate (FHR) for manifestations of distress.

A nurse is assisting with the care of a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (Select all that apply.) A. Encourage use of patterned breathing techniques. B. Insert an indwelling urinary catheter. C. Administer opioid analgesic medication. D. Suggest application of cold. E. Provide ice chips.

A. Encourage use of patterned breathing techniques. Patterned breathing techniques can assist with pain management at this time C. Administer opioid analgesic medication. An opioid analgesic can be safely administered at this time. D. Suggest application of cold. A nonpharmacological approach, such as the application of cold, is an appropriate intervention at this time.

A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? A. Fetal engagement B. Fetal lie C. Fetal attitude D. Fetal position

A. Fetal engagement Prior to an anatomy, it is imperative that the fetus is engaged at 0 station and at the level of the maternal ischial spines to prevent prolapse of the umbilical cord.

A nurse in labor and delivery unit is assisting with the care of a client in labor and applies an external fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are occurring every 8 min and 30 to 40 seconds in duration. The RN performs a vaginal exam and finds the cervix is 2 cm dilated and 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of labor is the client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. Second stage of labor

A. First stage, latent phase In stage 1, latent phase, the cervix dilates 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds.

A nurse is assisting in the care of a client who is in active labor. The nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate? A. Maternal fever B. Fetal heart failure C. Maternal hypoglycemia D. Fetal head compression

A. Maternal fever Tachycardia can be caused by maternal fever, infection, and chorioamnionitis.

A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse. Which of the following statements should the nurse include? A. "Count the fetal heart rate for 15 seconds to determine the baseline." B. "Auscultate the fetal heart rate immediately following rupture of membranes." C. "Count the fetal heart rate during a contraction to determine the baseline." D. "Auscultate the fetal heart rate every 30 minutes during the second stage of labor."

B. "Auscultate the fetal heart rate immediately following rupture of membranes." The nurse should auscultate the FHR immediately following rupture of membranes to monitor for changes that can indicate umbilical cord prolapse.

A nurse is reinforcing teaching with a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (Select all that apply.) A. "It is considered a noninvasive procedure." B. "It can detect abnormal fetal heart tones early." C. "It can determine the amount of amniotic fluid you have." D. "It allows for accurate readings despite maternal movement." E. "It can measure uterine contraction intensity."

B. "It can detect abnormal fetal heart tones early." A benefit of internal fetal monitoring is that it can detect abnormal fetal heart tones early. D. "It allows for accurate readings despite maternal movement." A benefit of internal fetal monitoring is that it allows for accurate readings despite maternal movement; external monitoring requires adjustment when the client moves. E. "It can measure uterine contraction intensity." A benefit of internal fetal monitoring is that it can measure uterine contraction intensity; external monitoring cannot.

A nurse is reinforcing teaching about external monitoring with a client who was recently admitted for induction of labor. Which of the following information should the nurse include? A. Membranes must be ruptured prior to monitor placement. B. There is an increased risk for infection when using an external monitor. C. External monitoring cannot measure intensity of contractions. D. The monitor must be applied by the provider or a nurse.

C. External monitoring cannot measure intensity of contractions. An intrauterine pressure catheter measures the intensity of uterine contractions.

A nurse is assisting with the care of a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states her water broke. The monitor reveals a FHR of 80 to 85/min. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first? A. Place the client in the Trendelenburg position. B. Apply finger pressure to the presenting part. C. Administer oxygen at 10 L/min via a face mask. D. Call for assistance.

D. Call for assistance. According to evidence-based practice, the nurse should first call for assistance.