Care of Women in Labor

A woman is 7 cm dilated and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, the nurse assesses the most likely explanation for the woman's change in behavior is that: a. Labor has progressed to the transition phase b. She lacked adequate preparation for the labor experience c. The woman would benefit from a different form of analgesia d. The contractions have increased from mild to moderate intensity

ANS: A If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.

The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a. Inform the mother that the rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high. c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast.

ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

On vaginal exam, the client's cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishop's score for this client is: a. 6. b. 9. c. 10. d. 12.

ANS: B On the Bishop's scoring system, an anterior cervix = 2 points, soft cervix = 2 points, 70% effaced = 2 points, 2 cm dilated = 1 point, and 0 station = 2 points, for a total score of 9.

The pregnant client expresses a desire to schedule birth during the baby's father's furlough from the Army. The nurse explains that prior to induction of labor, it is essential to determine which condition? a. Dilated cervix b. Fetal lung maturity c. Rupture of membranes d. Uterine hypertonia

ANS: B Reassurance of fetal lung maturity is essential before elective procedures such as induction or cesarean. The cervix must be favorable for dilation but need not be dilated prior to induction. Prior rupture of membranes is not necessary for induction. Uterine hypertonia is a risk factor associated with induction of labor.

The assessment finding which indicates that the client is in the active phase of the first stage of labor is: a. 80% effacement. b. dilation of 5 cm. c. presence of bloody show. d. regular contraction every 3 to 4 minutes.

ANS: B The active phase of labor is defined by cervical dilation between 4 to 7 cm. Effacement, bloody show, and regular contractions are not parameters whereby the phases of labor are defined.

The nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" What is the best nursing intervention? a. Find the physician. b. Stay with the woman and use the call bell to get help. c. Send the woman's partner to locate a registered nurse. d. Assist with deep breathing to slow the labor process.

ANS: B If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.

After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. What would increase the nurse's concern about this risk? a. Hypovolemia b. Iron deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency

ANS: C Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site.

The nurse explains that the function of contractions during the second stage of labor is to: a. Align the baby into the proper position for delivery b. Dilate and efface the cervix c. Push the baby out of the mother's body d. Separate the placenta from the uterine wall

ANS: C The contractions push the baby out of the mother's body as the second stage of labor ends with the birth of the baby.

What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/min. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8° C.

ANS: C Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.

What is the best nursing action to implement when late decelerations occur? a. Reposition the patient to supine b. Decrease flow of intravenous (IV) fluids c. Increase oxygen to 10 L/minute d. Prepare to increase oxytocin drip

ANS: C The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.

A client asks the nurse, "What can I do to avoid an episiotomy during birth?" Which responses should the nurse give? (Select all that apply). a. "Using the lithotomy position during pushing may be beneficial." b. "Using prolonged breath-holding when pushing may help stretch the tissue." c. "Beginning at 36 weeks, a daily 10-minute perineal massage may help stretch the tissue." d. "Using an open glottis technique when pushing can promote gradual perineal stretching." e. "Delaying pushing until the urge is felt can gradually distend the soft tissues of the pelvic floor."

ANS: C, D, E Daily perineal massage and stretching by the woman from 36 weeks until birth has been shown to reduce the risk for perineal trauma during birth. Pushing with an open glottis technique rather than prolonged breath-holding when pushing promotes gradual perineal stretching. Delaying pushing until the urge is felt gradually distends the soft tissues of the pelvic floor. An upright position while pushing promotes gradual stretching of the woman's perineum, not the lithotomy position.

As a perinatal nurse, you realize that a fetal heart rate (FHR) that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with: a. Hypotension b. Cord compression c. Maternal drug use d. Hypoxemia

ANS: D Nonreassuring heart rate patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Fetal variable decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.

A nurse documents that the fetal heart rate variability is marked. This indicates that the range is greater than how many beats per minute? Record your answer as a whole number. _____ bpm

ANS: 25 There are four categories of fetal heart rate variability: Absent: Amplitude range is undetectable Minimal: detectable to less than or equal to 5 beats/min Moderate (normal): 6 to 25 beats/min Marked: Range >25 beats/min

Which of the following is the priority intervention for the client in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? a. Administer O2 at 8 to 10 L/min. b. Decrease the IV rate to 100 mL/hr. c. Reposition the ultrasound transducer. d. Perform a vaginal exam to assess for cord prolapse.

ANS: A A deceleration that returns to baseline after the end of the contraction is a late deceleration caused by placental perfusion problems. Administering oxygen will increase the client's blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate, repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord prolapse are not effective interventions to improve fetal oxygenation.

Which condition is a contraindication for an amniotomy? a. -2 station b. Breech presentation c. Dilation less than 3 cm d. Right occiput posterior position

ANS: A A prolapsed cord can occur if the membranes artificially rupture when the presenting part is not engaged. The presenting part should be cephalic. The dilation must be enough to determine labor. Right occiput posterior is a cephalic presentation appropriate for an amniotomy

The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of: a. A well-oxygenated fetus b. Compression of the umbilical cord c. Compression of the fetal head d. Uteroplacental insufficiency

ANS: A Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

Which clinical findings would be considered to be normal for a preterm fetus during the labor period? a. Baseline tachycardia b. Baseline bradycardia c. Fetal anemia d. Acidosis

ANS: A Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

The labor nurse is providing care for a patient admitted for induction of labor at 38 weeks' gestation. The patient's Bishop score is 5, and an infusion of oxytocin (Pitocin) is initiated with orders that read as follows: mix 30 units of Pitocin in 500 mL of NS, increase the rate of infusion by 2 mL/hr every 15 to 60 minutes until a pattern of three contractions in 10 minutes is established. What is the priority nursing action for this patient? a. Increase the infusion of Pitocin every 30 to 60 minutes. b. Assess for changes in the patient's cervix every 2 hours. c. Obtain a reactive non-stress test prior to starting the infusion. d. Determine the fetal heart rate baseline for 30 minutes prior to starting the infusion.

ANS: A Cervical assessment estimates whether the cervix is favorable for induction. The Bishop scoring system is used to estimate cervical readiness for labor with five factors—cervical dilation, effacement, consistency, position, and fetal station. Vaginal birth is more likely to result if the Bishop score is higher than 8. This patient's Bishop score is low and she is at increased risk for an operative birth. Titration of Pitocin is at the judgment of the RN. A slower infusion of Pitocin allows more time for her body to adapt to the Pitocin and increases her potential for a nonoperative birth. Pitocin is a rapid-acting drug with an onset of 1 minute, duration of 30 minutes, and a half-life of 12 to 17 minutes. Cervical assessment is completed on an as-needed basis and is not scheduled. Assuring fetal well-being is important and can be determined by variability in the FHR baseline. A reactive non-stress test is not necessary prior to infusion. Establishing a baseline FHR prior to induction is a standard of care.

A nurse caring for a laboring woman is cognizant that early decelerations are caused by: a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: A Early decelerations are the fetus's response to fetal head compression. These are considered benign and interventions are not necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal heart rate (FHR) unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

Fetal tachycardia is most common during: a. Maternal fever b. Umbilical cord prolapse c. Regional anesthesia d. Magnesium sulfate administration

ANS: A Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. Umbilical cord prolapse will most likely result in fetal bradycardia, not tachycardia. Regional anesthesia will most likely result in fetal bradycardia, not tachycardia. Magnesium sulfate administration will most likely result in fetal bradycardia, not tachycardia.

Which description of the four stages of labor is correct for both definition and duration? a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours c. Third stage: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first-timer) d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

ANS: A Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage extends from birth to expulsion of the placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours).

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a. Has recovered from epidural or spinal anesthesia b. Has hidden bleeding underneath her c. Has regained some flexibility d. Is a candidate to go home after 6 hours

ANS: A If the numb or prickly sensations are gone from her legs after these movements, she likely has recovered from the epidural or spinal anesthesia. It is always important to assess the client for bleeding beneath her buttocks prior to discharge from the recovery room; however, she should be rolled to her side for this assessment. The nurse is not required to assess the woman for flexibility. This assessment is performed in order to evaluate if the client has recovered from spinal anesthesia, not to determine if she is a candidate for early discharge.

The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient's contractions. How will the nurse document these findings? a. Late decelerations b. Early decelerations c. Variable decelerations d. Proximal decelerations

ANS: A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contraction's peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal decelerations is not a recognized term.

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: a. Change the woman's position b. Notify the health care provider c. Assist with amnioinfusion d. Insert a scalp electrode

ANS: A Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, the nurse should continue with subsequent intrauterine resuscitation measures, including notifying the health care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The fetal heart rate pattern associated with this situation most likely will reveal variable decelerations. A fetal scalp electrode provides accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that will alleviate late decelerations, nor is it the nurse's first priority.

After birth of the placenta the patient states, "All of a sudden I feel very cold." What is the best nursing action in response to this statement? a. Place a warm blanket over the patient. b. Place the baby on the patient's abdomen. c. Tell the patient that chills are expected after birth. d. "What do you mean by your words 'very cold'?"

ANS: A Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary.

When a hypotonic labor dysfunction occurs in a patient who is dilated to 5 cm with membranes intact, the nurse informs the patient that the physician most likely will: a. Perform an amniotomy b. Initiate tocolytic drugs c. Order a sedative for the patient d. Plan to do an emergency cesarean section

ANS: A Medical treatment for hypotonic labor dysfunction includes an amniotomy if the membranes are intact as the first remedy.

The nurse observes the following data on an electronic fetal monitor attached to a client in the active phase of the first stage of labor: fetal heart rate baseline, 125 to 140 bpm, three accelerations over the course of 20 minutes, moderate variability. What is the priority action based on these findings? a. Document the findings. b. Contact the health care provider. c. Increase the rate of the existing IV to 200 mL/hr as per the standing prescription. d. Place oxygen via a rebreather mask at 10 L/min as per the standing prescription.

ANS: A The findings are all within normal limits for the laboring client. Accelerations are usually a reassuring sign. Normal fetal heart rate is 110 to 160 bpm and of moderate variability; amplitude range of 6 to 25 bpm is desirable. No intervention is required because the pattern suggests that the fetus has adequate reserves to tolerate intrapartum stressors.

In assisting with the two factors that have an effect on fetal status, namely pushing and positioning, nurses should: a. Encourage the woman's cooperation in avoiding the supine position b. Advise the woman to avoid the semi-Fowler position c. Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response d. Instruct the woman to open her mouth and close her glottis, letting air escape after the push

ANS: A The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. Encouraging the woman to hold her breath and tighten her abdominal muscles is the Valsalva maneuver, which should be avoided. Both the mouth and glottis should be open, letting air escape during the push.

A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action? a. Stop the infusion of Pitocin. b. Reposition the patient from her right to her left side. c. Perform a vaginal exam to assess for a prolapsed cord. d. Prepare the patient for an emergency cesarean section.

ANS: A There are multiple reasons for late decelerations. Address the probable cause first, such as uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations. Repositioning can increase oxygenation to the fetus but does not address the cause of the problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of moderate variability, the fetus continues to have adequate oxygen reserves. The presence of two or more nonreassuring fetal heart rate patterns increases the level of concern.

When a laboring client receiving 12 mU of pitocin for induction develops a contraction pattern of every 2 minutes lasting 80 seconds and recurring late decelerations, the nurse should immediately: a. stop oxytocin infusion. b. administer O2 at 8 TO 10 L/min. c. reposition client to left side-lying position. d. increase the rate of the primary nonadditive infusion.

ANS: A Uterine hyperstimulation can reduce placental blood flow and decrease fetal oxygenation. Late decelerations are caused by uteroplacental insufficiency. Stopping the oxytocin infusion will reduce uterine activity and increase fetal oxygenation. Administering O2, repositioning the client, and increasing the rate of the primary nonadditive infusion will not be effective until hyperstimulation is resolved.

The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate? a. A well-oxygenated fetus b. Compression of the umbilical cord c. Compression of the fetal head d. Uteroplacental insufficiency

ANS: A Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the most appropriate nursing intervention? a. Count respirations and report a rate of less than 12 breaths/min. b. Count respirations and report a rate of more than 20 breaths/min. c. Check blood pressure and report a rate of less than 100/60 mm Hg. d. Monitor urinary output and report a rate of less than 100 mL/hr.

ANS: A Excessive magnesium sulfate may cause respiratory depression.

An important part of fetal surveillance is assessment and documentation of the fetal heart rate during the first stage of labor. In the low-risk patient assessments for variability and periodic changes if using the fetal monitor should be done a. Every 15-30 minutes b. Every 5-15 minutes c. Every 30-60 minutes d. Only before and after ambulation

ANS: A Feedback A-During the active first stage of labor, FHR should be assessed every 15-30 minutes just after a contraction. B-During the second stage of labor the FHR should be assessed every 5-15 minutes. C-This is not an adequate assessment during any stage of labor. D-The FHR should also be evaluated both before and during ambulation.

Perinatal nurses are legally responsible for a. Correctly interpreting FHR patterns, initiating appropriate nursing interventions, and documenting the outcomes b. Greeting the patient on arrival, assessing her, and starting an IV line c. Applying the external fetal monitor and notifying the care provider d. Making sure the woman is comfortable

ANS: A Feedback A-Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions. B-These activities should be performed when any patient arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions. C-This is a nursing function that is part of the standard of care for all obstetrical patients. This falls within the RN scope of practice. D-Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable.

The nurse caring for the woman in labor should understand that absent or minimal variability is classified as either abnormal or indeterminate. Which condition related to decreased variability is considered benign? a. A periodic fetal sleep state b. Extreme prematurity c. Fetal hypoxemia d. Pre-existing neurologic injury

ANS: A Feedback A-When the fetus is temporarily in a sleep state there is minimal variability present. Periodic fetal sleep states usually last no longer than 30 minutes. B-A woman who presents in labor with extreme prematurity may display a FHR pattern of minimal or absent variability. C-Abnormal variability may also be related to fetal hypoxemia and metabolic acidemia. D-Congenital anomalies or pre-existing neurologic injury may also present as absent or minimal variability. Other possible causes might be CNS depressant medications, narcotics or general anesthesia.

What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation? a. Fetal distress b. Fetal maturity c. Intact gastrointestinal tract d. Dehydration in the mother

ANS: A Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.

A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the woman's change in behavior? a. Labor has progressed to the transition phase. b. She lacked adequate preparation for the labor experience. c. The woman would benefit from a different form of analgesia. d. The contractions have increased from mild to moderate intensity.

ANS: A If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.

A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism

ANS: A Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken.

The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the objective of magnesium sulfate therapy for this patient? a. To prevent convulsions b. To promote diaphoresis c. To increase reflex irritability d. To act as a saline cathartic

ANS: A Magnesium sulfate is a central nervous system depressant given to prevent seizures.

A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse's initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask.

ANS: A Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

What does the nurse explain is used to soften the cervix with a "cervical ripening" agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation

ANS: A Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.

The physician performs an amniotomy on a laboring woman. What will be the nurse's priority assessment immediately following this procedure? a. Fetal heart rate b. Fluid amount c. Maternal blood pressure d. Deep tendon reflexes

ANS: A The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes.

Which interventions are required following an amniotomy procedure? (Select all that apply.) a. Notation related to amount of fluid expelled b. Color and consistency of fluid c. Fetal heart rate d. Maternal blood pressure e. Maternal heart rate

ANS: A, B, C Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

Which adverse effects can be seen in response to administration of oxytocin (Pitocin) for induction of labor? (Select all that apply.) a. Maternal hyponatremia b. Uterine tachysystole c. Maternal hypotension d. Reassuring fetal heart pattern e. Decreased variability on fetal tracing

ANS: A, B, C The administration of Pitocin can lead to a decrease in maternal serum sodium levels because of water intoxication. With regard to uterine effects, Pitocin can cause hyperstimulation or uterine tetany to occur, along with maternal hypotension. In terms of fetal response, Pitocin administration can lead to a nonreassuring fetal heart rate pattern manifested as bradycardia, tachycardia, and/or late decelerations and a decrease in variability, resulting in fetal compromise.

A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.) a. Insert IV. b. Record a baseline fetal heart rate. c. Explain procedure to patient. d. Instruct patient to ambulate immediately afterward. e. Ensure a tocolytic is available.

ANS: A, B, C The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded.

What do late decelerations indicate? (Select all that apply.) a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression d. Cord compression e. Head compression

ANS: A, B, C This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged decelerations indicate cord compression and early decelerations indicate head compressions.

Five essential components of any fetal heart rate (FHR) tracing must be evaluated regularly. These include (choose all that apply): a. Baseline rate b. Baseline variability c. Accelerations d. Decelerations e. Changes or trends over time f. Frequency of contractions

ANS: A, B, C, D, E The five essential components of the FHR tracing that must be evaluated regularly are baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time. Whenever one of these five essential components is assessed as abnormal, corrective measures must immediately be taken. Contraction frequency is not an essential component of the FHR tracing.

What complications of overstimulation of uterine contractions may occur? (Select all that apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture

ANS: A, B, E The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention.

The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.) a. Maternal hypotension b. Fetal heart rate of 140 to 150 bpm c. Meconium-stained amniotic fluid d. Maternal fever—38° C (100.4° F) or higher e. Complete uterine relaxation of more than 30 seconds between contractions

ANS: A, C, D Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38° C [100.4° F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

The nurse is obtaining history and physical information on a new patient attending her first prenatal visit. After recording current height, weight, and BMI, it is determined that the patient is obese. What complications related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.) a. Gestational diabetes b. RH Incompatibility c. Hypertension d. Pre-eclampsia e. Infection

ANS: A, C, D The obese woman who is pregnant has a high risk for developing complications during pregnancy such as gestational diabetes, hypertension, cardiac problems, pre-eclampsia, and respiratory problems.

Induction of labor is considered an acceptable obstetric procedure if it is a safe time to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction, including which of the following? Select all that apply. a. Rupture of membranes at or near term b. Convenience of the woman or her physician c. Chorioamnionitis (inflammation of the amniotic sac) d. Postterm pregnancy e. Fetal death

ANS: A, C, D, E Feedback Correct A, C, D, E. These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Incorrect B. Elective inductions for convenience of the woman or her provider are not recommended; however, they have become common. Factors such as rapid labors and living a long distance from a health care facility may be a valid reason in such a circumstance.

The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a. Bloody b. Clear with bits of vernix caseosa c. Green and thick d. Yellow and cloudy with foul odor

ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.`

What three measures should the nurse implement to provide intrauterine resuscitation? Select the best response that indicates the priority of actions that should be taken, starting with the most important. a. Call the provider, reposition the mother, and perform a vaginal exam. b. Provide oxygen via face mask, reposition the mother, and increase IV fluid. c. Administer oxygen to the mother, increase IV fluid, and notify the health care provider. d. Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.

ANS: B Basic interventions for management of any abnormal fetal heart rate pattern includes administer oxygen by nonrebreather face mask at a rate of 8 to 10 L/min, assist the woman to a side-lying (lateral) position, and increase blood volume by increasing the rate of the primary IV infusion. The purpose of these interventions is to improve uterine blood flow and intervillous space blood flow and increase maternal oxygenation and cardiac output. The term intrauterine resuscitation is sometimes used to refer to these interventions. Basic corrective measures include providing O2, instituting maternal position changes, and increasing IV fluid volume. If these interventions do not resolve the fetal heart rate issue quickly, the primary provider should be notified immediately. In this scenario the nurse failed to alter the woman's position. To improve uterine blood flow, the woman should be repositioned onto her side. If these interventions do not resolve the fetal heart rate issue quickly, the primary provider should be notified immediately. Performing a vaginal examination would not be helpful at this time. In this scenario the nurse should have begun by applying O2 at 8 to 10 L/min by nonrebreather face mask.

The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour

ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications

Nursing care before a cesarean birth should include: a. full perineal shave preparation. b. administering a clear oral antacid. c. injection of narcotic preoperative medications. d. straight catheterization to empty the bladder.

ANS: B General anesthesia may be needed unexpectedly for cesarean birth. An oral antacid neutralizes gastric acid and reduces potential lung injury if the client vomits and aspirates gastric contents during anesthesia. Perineal preparation is not necessary for a cesarean section. Some agencies will do an abdominal prep just before the surgery. A narcotic at this point would put the fetus at high risk for respiratory distress. The catheterization should be indwelling to keep the bladder small during the surgery.

When the client receiving an oxytocin (Pitocin) drip at 16 mU/min develops hypertonic stimulation, FHR 138 bpm with accelerations, and no decelerations, the nurse's best response would be to: a. stop the drip immediately. b. decrease the dose to 14 mU/min. c. reassess the patient at 5 minute intervals. d. reposition the patient to the left side-lying position.

ANS: B In the absence of any adverse fetal response, hypertonic stimulation can be managed by reducing the infusion rate by 1 to 2 mU/min until uterine hyperstimulation is resolved. Stopping the drip immediately is not necessary unless hyperstimulation continues and adverse fetal responses occur. Reassessing and repositioning are of no benefit in this situation.

Which characteristic correctly matches the type of deceleration with its likely cause? a. Early deceleration—umbilical cord compression b. Late deceleration—uteroplacental insufficiency c. Variable deceleration—head compression d. Prolonged deceleration—cause unknown

ANS: B Late deceleration is caused by uteroplacental insufficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? a. Latent: mild, regular contractions; no dilation; bloody show b. Active: moderate, regular contractions; 4 to 7 cm dilation c. Lull: no contractions; dilation stable d. Transition: very strong but irregular contractions; 8 to 10 cm dilation

ANS: B The active phase is characterized by moderate, regular contractions, 4 to 7 cm dilation, and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions, dilation up to 3 cm, brownish to pale pink mucus, and a duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions, 8 to 10 cm dilation, and a duration of 20 to 40 minutes.

During labor a fetus with an average fetal heart rate (FHR) of 135 beats/min over a 10-minute period is considered to have: a. Bradycardia b. A normal baseline heart rate c. Tachycardia d. Hypoxia

ANS: B The baseline heart rate is measured over 10 minutes; a normal range is 110 to 160 beats/min. Bradycardia is a FHR less than 110 beats/min for 10 minutes or longer. Tachycardia is a FHR more than 160 beats/min for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of this condition exists with a baseline heart rate in the normal range.

The priority nursing intervention following an amniotomy is to: a. change the client's gown. b. assess the fetal heart rate. c. assess the color of the amniotic fluid. d. estimate the amount of amniotic fluid.

ANS: B The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Changing the gown is important for client comfort but is not the top priority. Assessing the amount of amniotic fluid is important but is not the top priority. Estimating the amount of amniotic fluid is not a top priority for this client.

A woman who has a history of sexual abuse may have a number of traumatic memories triggered during labor. She may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention is key for the nurse to use while providing care? a. Tell the client to relax and that it won't hurt much b. Limit the number of procedures that invade her body c. Reassure the client that as the nurse you know what is best d. Allow unlimited care providers to be with the client

ANS: B The number of invasive procedures such as vaginal examinations, internal monitoring, and IV therapy should be limited as much as possible. The nurse should always avoid words and phrases that may result in the client's recalling the phrases of her abuser (i.e., "Relax, this won't hurt" or "Just open your legs"). The woman's sense of control should be maintained at all times. The nurse should explain procedures at the client's pace and wait for permission to proceed. Protecting the client's environment by providing privacy and limiting the number of staff who observe the client will help to make her feel safe.

Nurses alert to signs of the onset of the second stage of labor can be certain that stage has begun when: a. The woman has a sudden episode of vomiting b. The nurse is unable to feel the cervix during a vaginal examination c. Bloody show increases d. The woman involuntarily tries to bear down

ANS: B The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced. Sudden vomiting is a suggestion of second-stage labor; however, the only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced. Bloody show increases during the second stage of labor; however, the inability to feel the cervix is an objective sign that the second stage has begun. The urge to bear down is a suggestion of second-stage labor. The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced.

The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 99° F [37.2° C]. What is the priority nursing action for this patient? a. Fetal acoustic stimulation b. Assess temperature every 2 hours c. Change absorption pads under her hips every 2 hours d. Review white blood cell count (WBC) drawn at admission

ANS: B The woman's temperature should be assessed at least every 2 to 4 hours after the membranes rupture. Elevations above 38° C (100.4° F) should be reported. A rising FHR and fetal tachycardia (above 160 bpm) may precede maternal fever. The fetal heart rate is at the high end of the acceptable range and the maternal temperature is slightly above normal. These parameters warrant watching closely with more frequent vital signs. The WBC is often falsely elevated in labor, largely related to the stress of labor. The FHR with a baseline of 150 to 160 bpm demonstrates moderate variability, and fetal acoustic stimulation is not warranted. Amniotic fluid is emitted from the vagina at variable rates and the underpad needs to be changed as needed.

Through vaginal examination, the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3½ to 4 minutes. The nurse reports this as: a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage, latent phase

ANS: B This maternal progress indicates that the woman is in the active phase of the first stage of labor. During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilation with contractions every 5 to 30 minutes. During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes. During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of "laboring down."

The nurse providing care for the laboring woman understands that variable fetal heart rate (FHR) decelerations are caused by: a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Fetal hypoxemia

ANS: B Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in the FHR. Fetal hypoxemia results in tachycardia initially, then bradycardia if hypoxia continues.

A nursing priority during admission of a laboring client who has not had prenatal care is: a. obtaining admission labs. b. identifying labor risk factors. c. discussing her birth plan choices. d. explaining importance of prenatal care.

ANS: B When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed.

When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? a. Early decelerations b. Variable decelerations c. Nonperiodic accelerations d. Increase in baseline variability

ANS: B When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. Early declarations are considered reassuring; they are not a concern after rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Increase in baseline variability is not an expected occurrence after the rupture of membranes.

When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor? a. By decreasing a woman's pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greater muscle tension

ANS: B Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

During the active phase of labor, the FHR of a low-risk patient should be assessed every a. 15 minutes b. 30 minutes c. 45 minutes d. 1 hour

ANS: B Feedback A-15-minute assessments are appropriate for a fetus at high risk. B-For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. C-45-minute assessments during the active phase of labor is not frequent enough to monitor for complications. D-1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

An indication for an episiotomy would be a woman who a. Has a routine vaginal birth b. Has fetal shoulder dystocia c. Is delivering a preterm infant d. Has a history of rapid deliveries

ANS: B Feedback A-Once routine for all vaginal deliveries, the perceived benefits of reducing pain and perineal tearing have not proven true. B-An episiotomy is indicated in the situation where the shoulder of the fetus become lodged under the mother symphysis during birth. C-A preterm infant is smaller and does not need as much space for delivery. D-Rapid deliveries are not an indication for a mediolateral episiotomy.

A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage

ANS: B Feedback A-The latent phase is from the beginning of true labor until 3 cm of cervical dilation. B-The active phase of labor is characterized by cervical dilation of 4 to 7 cm. C-The second stage of labor begins when the cervix is completely dilated until the birth of the baby. D-The third stage of labor is from the birth of the baby until the expulsion of the placenta.

The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow from placenta. d. Relax the cervix.

ANS: B Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.

During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub.

ANS: B Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.

When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.) a. Check the DTR each shift. b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. e. Provide food, as tolerated, during the course of labor.

ANS: B, C, D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

The health care provider has asked the nurse to prepare for an amniotomy. What is the nurse's priority action with this procedure? a. Perform Leopold's maneuvers. b. Determine the color of the amniotic fluid. c. Assess the fetal heart rate immediately after the procedure. d. Prepare the patient for a change in her pain level after the procedure.

ANS: C An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopold's maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor.

The priority nursing care associated with an oxytocin infusion is: a. measuring urinary output. b. evaluating cervical dilation. c. monitoring uterine response. d. increasing infusion rate every 30 minutes.

ANS: C Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurse's priority intervention is monitoring uterine response. Monitoring urinary output is important with Pitocin but not the top priority. Monitoring labor progression is important but not the top priority. The infusion rate may be increased but only after proper assessment that it is appropriate.

A nulliparous woman who has just begun the second stage of her labor most likely: a. Experiences a strong urge to bear down b. Shows perineal bulging c. Feels tired yet relieved that the worst is over d. Shows an increase in bright red bloody show

ANS: C Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because "the worst is over." The woman may be very quiet during this phase. During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor.

Which of the following is the priority intervention for a supine client whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? a. Increase IV infusion. b. Elevate lower extremities. c. Reposition to left side-lying position. d. Administer oxygen per face mask at 4 to 6 L/min.

ANS: C Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the client is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the client is in a supine position.

Select the situation that describes the safest administration of oxytocin induction and cervical ripening agents. a. Concurrent use of oxytocin and dinoprostone (Cervidil) b. Misoprostol (Cytotec) 25 mcg, followed in 4 hours by oxytocin induction in vaginal birth after cesarean section (VBAC) client c. Dinoprostone (Cervidil) 10 mg in place for 12 hours followed by oxytocin induction in 1 hour d. Maximum dose of dinoprostone (Prepidil) 2 mg/24 hr followed in 4 hours by oxytocin induction

ANS: C Dinoprostone (Cervidil) in a 10-mg, time-release insert may be left in place for up to 12 hours and oxytocin induction can be safely started 1 hour after insert is removed. Oxytocin and cervical ripening agents cannot be administered at the same time. Misoprostol (Cytotec) is contraindicated in a women with previous cesarean. The maximum dose of dinoprostone (Prepidil) 1.5 mg/24 hr.

The nurse knows that the second stage of labor, the descent phase, has begun when: a. The amniotic membranes rupture b. The cervix cannot be felt during a vaginal examination c. The woman experiences a strong urge to bear down d. The presenting part is below the ischial spines

ANS: C During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes (ROM) has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm dilation.

The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor? a. Every 10 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes

ANS: C Evaluate the fetal monitoring strip systematically for the elements noted. The following are recommended assessment and documentation intervals for IA and EFM (although facility policies may be different): low-risk women, every 30 minutes during the active phase and every 15 minutes during the second stage.

A nurse caring for a woman in labor understands that maternal hypotension can result in: a. Early decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

ANS: C Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early decelerations. Maternal hypotension is not associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.

A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a. Obtain a fetal heart rate. b. Determine the estimated due date. c. Auscultate anterior and posterior breath sounds. d. Ask the client when she last had something to eat.

ANS: C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

The pregnant client is admitted to the labor and birth unit for induction of labor. Which finding would allow the induction to continue as planned? a. Abruptio placentae b. Cephalopelvic disproportion c. Ripening of the cervix d. Umbilical cord prolapse

ANS: C Procedures to ripen (soften) the cervix and make it more likely to dilate with the forces of labor are a common adjunct to induction. Most are done the day before the scheduled induction. Contraindications associated with induction may include cephalopelvic disproportion and umbilical cord prolapse. A cesarean section is indicated for abruptio placentae.

Which of the following factors would lead to an increased risk for a prolapsed cord to occur during an amniotomy? a. Presenting part engaged b. Postdated pregnancy c. Preterm pregnancy d. Term pregnancy

ANS: C Prolapsed cord is more likely to occur when the presenting part is not engaged and the pregnancy is preterm because the fetus would be smaller and there would potentially be more amniotic fluid. If the presenting part is engaged and the pregnancy is at term or postdated, it is less likely that a prolapsed cord would occur.

The nurse caring for a woman in labor understands that prolonged decelerations: a. Are a continuing pattern of benign decelerations that do not require intervention b. Constitute a baseline change when they last longer than 5 minutes c. Are caused by a disruption to the fetal O2 supply d. Require the usual fetal monitoring by the nurse

ANS: C Prolonged decelerations are caused by a disruption in the fetal oxygen supply. They usually begin as a reflex response to hypoxia. If the disruption continues, the fetal cardiac tissue itself will become hypoxic, resulting in direct myocardial depression of the FHR. These can be caused by prolonged cord compression, uteroplacental insufficiency, or perhaps sustained head compression. Prolonged decelerations lasting more than 10 minutes are considered a baseline change that may require intervention. A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in fetal heart rate (FHR) of at least 15 beats/min below the baseline and lasting more than 2 minutes but less than 10 minutes. Nurses should notify the physician or nurse-midwife immediately and initiate appropriate treatment of abnormal patterns when they see a prolonged deceleration.

In which client situation could an amniotomy be safely performed? a. G1 P0, 38 weeks' gestation, 20% effaced, closed cervix b. G2 P1, 40 weeks' gestation, with fetus in a breech presentation c. G2 P0, 39 weeks' gestation, 70% effaced, cervix dilated 2 cm d. G3 P2, 41 weeks' gestation, early labor complicated with hydramnios

ANS: C The cervix must be partially open to allow the membranes to be ruptured. An amniotomy cannot be performed when the cervix is closed. Breech presentation would be delivered by cesarean section and membranes would be ruptured at birth. Rupturing the membranes in a client with hydramnios can result in abruptio placentae.

A client who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority? a. Increase rate of Pitocin infusion to help spread out contraction pattern. b. Place oxygen on client at 8 to 10 L/min via face mask and turn client to left side. c. Stop Pitocin infusion. d. Call physician to obtain an order for initiation of magnesium sulfate.

ANS: C The client is exhibiting uterine tachysystole (uterine tetany). Priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be called for additional orders.

A vaginal exam for a laboring multipara client who is 42 weeks' gestation reveals the following information: 4 cm, minimal effacement, -2 station. Which clinical factors would affect the clinical management decision not to rupture membranes with an AmniHook? a. Vaginal dilation b. Client is a multipara c. Presenting part is at -2 station d. Gestational age

ANS: C The fact that the presenting part is not engaged causes concern because there is increased risk of a prolapsed cord on artificial rupture of membranes (AROM). Vaginal dilation is adequate for attempt to rupture membranes. The fact that a client is a multipara is not a significant reason to affect clinical decision making with regard to AROM. Postdates of pregnancy may warrant a more aggressive approach to speed the labor and birth process.

When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? a. Reposition the client. b. Apply a fetal scalp electrode. c. Record this reassuring pattern. d. Administer oxygen by nasal cannula.

ANS: C The periodic pattern described is early deceleration that is not associated with fetal compromise and requires no intervention. It is a reassuring pattern. Repositioning the client, applying a fetal scalp electrode, or administering oxygen would be interventions done for nonreassuring patterns.

The nurse providing care for a high risk laboring woman is alert for late fetal heart rate (FHR) decelerations. These late decelerations may be caused by: a. Altered cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Meconium fluid

ANS: C Uteroplacental insufficiency results in late decelerations in the FHR. Altered fetal cerebral blood flow results in early decelerations in the FHR. Umbilical cord compression results in variable decelerations in the FHR. Meconium-stained fluid may or may not produce changes in the fetal heart rate, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.

A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, "Will I be able to deliver vaginally?" What explanation by the nurse is the most appropriate? a. "Yes, you can deliver vaginally until 36 weeks." b. "A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done." c. "A cesarean section is performed when the mother has a total placenta previa." d. "There is no reason why you cannot have a vaginal delivery."

ANS: C A cesarean delivery is done for a partial or total placenta previa.

Why is the relaxation phase between contractions important? a. The laboring woman needs to rest. b. The uterine muscles fatigue without relaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progresses toward delivery at these times.

ANS: C Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.

What drug will the nurse plan to have available for immediate IV administration whenever magnesium sulfate is administered to a maternity patient? a. Ergonovine maleate (Ergotrate) b. Oxytocin c. Calcium gluconate d. Hydralazine (Apresoline)

ANS: C Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a woman receives magnesium sulfate.

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.

ANS: C Feedback A-Birth of the head occurs when the station is +4. A 0 station indicates engagement. B-Bloody show occurs throughout the labor process and is not an indication of an imminent birth. C-A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. D-Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.

A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency

ANS: C Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.

What contraction duration and interval does the nurse recognize could result in fetal compromise? a. Duration shorter than 30 seconds, interval longer than 75 seconds b. Duration shorter than 90 seconds, interval longer than 120 seconds c. Duration longer than 90 seconds, interval shorter than 60 seconds d. Duration longer than 60 seconds, interval shorter than 90 seconds

ANS: C Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurse's initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula.

ANS: C Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.

What is the function of contractions during the second stage of labor? a. Align the infant into the proper position for delivery b. Dilate and efface the cervix c. Push the infant out of the mother's body d. Separate the placenta from the uterine wall

ANS: C The contractions push the infant out of the mother's body as the second stage of labor ends with the birth of the infant.

A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report immediately? a. Diarrhea b. Urticaria c. Blurred vision d. Backache

ANS: C Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for effective intervention to prevent preeclampsia and convulsion.

The nurse is planning care for a client who just received 25 mcg of misoprostol (Cytotec) vaginally to ripen the cervix. Which interventions should the nurse plan to implement? (Select all that apply.) a. Assist the client to the bathroom. b. Position the client in a high Fowler position. c. Assess the uterus for excessive contractions. d. Monitor the fetal heart rate for at least 30 minute

ANS: C, D The FHR should be monitored for at least 30 minutes for changes and the uterus should be assessed for excessive contractions. To reduce leakage, the woman should lie flat for 15 to 20 minutes after the gel form of prostaglandin is inserted. The client should not be assisted to the bathroom immediately or placed in a high Fowler position (head of bed up 90 degrees).

The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration? Select all that apply. a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the baby's neck e. Maternal supine hypotension

ANS: C, E Feedback Correct Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by: uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Incorrect Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination and placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the cord is around the baby's neck, arm, leg or other body part, a short cord, a knot in the cord or a prolapsed cord.

Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours? a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process

ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance

The gynecologist performs an amniotomy. What will the nurse's role include immediately following the procedure? a. Assessing for ballottement b. Conducting a pH and/or fern test c. Labeling of specimens for chromosomal analysis d. Recording the character and amount of amniotic fluid

ANS: D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

A pregnant woman develops hypertension. The nurse monitors the client's blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with what complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow

ANS: D Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension.

Which fetal heart rate (FHR) finding concerns the nurse during labor? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/min d. Late decelerations

ANS: D Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected. Accelerations in the FHR are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they generally are not a concern during normal labor. An FHR finding of 126 beats/min is normal and not a concern.

To monitor for potential hemorrhage in the client who has just had a cesarean birth, which action should the recovery room nurse implement? a. Monitor her urinary output. b. Maintain an intravenous infusion at 1 mL/hr. c. Assess the abdominal dressings for drainage. d. Assess the uterus for firmness every 15 minutes.

ANS: D Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room.

A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely: a. abnormal labor. b. a sign that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor.

ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

Which should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Fetal heart rate in the 140s c. Contractions lasting 90 seconds d. Meconium-stained amniotic fluid

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section." The most appropriate nursing diagnosis is: a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience

ANS: D Women who have cesarean birth usually need greater support than those having vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.

The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction d. Use of frequent position changes

ANS: D A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor.

A pregnant woman is at 38 weeks of gestation. She wants to know if any signs indicate "labor is getting closer to starting." The nurse informs the woman that which of the following is a sign that labor may begin soon? a. Weight gain of 1.5 to 2 kg (3 to 4 lb) b. Increase in fundal height c. Urinary retention d. Surge of energy

ANS: D Feedback A-The woman may lose 0.5 to 1.5 kg, the result of water loss caused by electrolyte shifts, which in turn are caused by changes in the estrogen and progesterone levels. B-When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. C-Urinary frequency may return before labor. D-Women speak of having a burst of energy before labor.

What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push? a. "At the beginning of a contraction, hold your breath and push for 10 seconds." b. "Take a deep breath and push between contractions." c. "Begin pushing when a contraction starts and continue for the duration of the contraction." d. "At the beginning of a contraction, take two deep breaths and push with the second exhalation."

ANS: D When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling.

Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section." What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience

ANS: D Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.