Chapter 10: Nursing Care during Labor and Birth

A nursing instructor is teaching students about the labor and delivery process and recognizes a need for further teaching when overhearing a student make which statement?

"Anxiety can speed up the labor process."

A maternal health nurse is triaging a pregnant woman who reports vaginal bleeding. Which question made by the nurse best assesses the client's condition?

"How many times have you changed sanitary napkins?" If a woman reports vaginal bleeding, the best assessment question is one that determines the number of sanitary napkins soiled. This determines how heavy the flow is and should be the priority. The remaining questions may be asked by the nurse; however, these are not the best questions to assess the client's condition.

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

"The temperature of the water should be at least 105℉ (40.5℃)."

The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data?

A urine dipstick test to check for protein

At which time is it most important to monitor for umbilical cord prolapse?

After rupture of membranes

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?

Assess and reposition the woman.

The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the LPN, is completed first?

Assess if the bladder is distended

Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Check the fetal heart rate.

In the labor and delivery unit, which is the best way to prevent the spread of infection?

Complete hand hygiene

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?

Continue to monitor the client and the FHR

The nurse is caring for a client who is a gravida 2 para 1 and had a previous cesarean section. The client has had no complications with the pregnancy and prefers to have this delivery vaginally. Which monitoring system best assesses for the ability to delivery vaginally?

Continuous internal monitoring of uterine contractions

It is most likely that the physician would consider performing an amnioinfusion if the EFM tracing shows which of the following?

Deep variable decelerations more than 60 bpm below the baseline with every contraction

The nurse is preparing to perform the Leopold maneuvers on a pregnant client. Which action occurs first?

Determine the presentation

Which nursing action is applied throughout all stages of labor?

Do not allow the client to lay flat on her back for long periods.

Mrs. Timms is now in the transition phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the woman's breathing pattern to be effective, what outcome would you expect?

Does not hyperventilate

A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritize at this time?

Ensure cervix fully dilated

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

Lie on her side so she is comfortable.

The nurse notes that the client has a moderate amount of bleeding after birth. Which instruction is anticipated to control bleeding?

Put the newborn to the breast to suck.

The client pushes and the baby's head emerges. External rotation begins, but the baby's chin is drawn back just inside the vagina. The nurse recognizes that additional providers are needed in the delivery room. What emergency protocol does the nurse call?

Shoulder dystocia

The obstetric nurse is monitoring a client during the third stage of labor. What change in status should the nurse prioritize and report?

Sudden chest pain

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data?

The client has saturated three sanitary napkins in the past 4 hours.

The nurse is analyzing the electronic fetal monitoring tracing. Which report to the registered nurse is most accurate?

The client is having late decelerations.

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring?

The client who is very restless and is moving around in the bed

Which psychosocial state is anticipated when the client enters the active phase of labor?

The client will become more quiet and introverted.

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR.

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR?

between the umbilicus and the symphysis pubis

A patient arrives at the birthing suite and tells the nurse that she believes she is in labor. Which assessments should the nurse prioritize at this time? Select all that apply.

birth imminence fetal status risk factors maternal status

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:

blue.

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present?

cervical dilation (dilatation) of 2 cm or more

A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?

encouraging the woman to push when she has a strong desire to do so

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

every 15 minutes

The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor?

every 15 to 30 minutes

A client is ready to push. The nurse instructs her to push vigorously and grunt and breathe out during a pushing effort. What would be important to monitor on the client while she is pushing vigorously?

fatigue

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding?

less anxiety

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?

moderate

When the client in the transition phase of labor experiences dizziness and tingling in the fingers and around the mouth from hyperventilation, the client is anticipated to be in:

respiratory alkalosis.

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?

respiratory depression

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?

sudden gush of dark blood from the vagina

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

tachycardia and a falling blood pressure

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?

"Unfortunately, I'm going to have to stay quite still in bed while it is in place."

A woman who has been in labor for a few hours is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat?

"You could have some hard candy to suck on."

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less.

A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response?

A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently.

Which assessment findings indicate a distressed fetus? Select all that apply.

Absent accelerations Late deceleration patterns Persistent bradycardia

A nursing instructor is conducting a session introducing a group of nursing students to the various pieces of equipment used for intermittent fetal monitoring. The instructor determines the session is successful after the students correctly choose which methods can be used? Select all that apply.

Doppler fetoscope external fetal monitor

The nurse is performing Leopold maneuvers as part of the initial assessment. Which action would the nurse do first?

Feel for the fetal buttocks or head while palpating the abdomen.

When assessing a client in labor, the nurse observes that the fetal heart rate (FHR) gradually falls from 150 bpm to 132 bpm during the contraction and returns to baseline at the end of the contractions. The nurse interprets this finding as associated with which possible condition?

Fetal head compression

The nurse is monitoring a client at 38 weeks' gestation who is bleeding. Which assessment findings indicate the client is hemodynamically unstable? Select all that apply.

Fetal heart rate 198 bpm Urine output: 20 ml/hr

When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being?

Fetal heart rate acceleration occurs.

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?

Have the client pant and blow through the contraction.

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Help the woman change positions.

Which is the most important factor on how much admission data is obtained when a client reports to the hospital in labor?

Imminence of birth

Which symptoms indicate that the client has begun the transition phase of labor? Select all that apply.

Increase in bloody show The client states an urge to push Irritability and restlessness may occur The client may begin to cry Hyperventilation may occur

A G2 P1 client, at 37 weeks' gestation, arrives to the unit and announces, "I am pretty sure my water broke about half an hour ago." What action should the LPN prioritize for this client while checking her in?

Inform the RN that your client may have ruptured membranes

Which nursing instruction is best when helping the woman deliver the fetus in a controlled manner?

Instruct the client to blow through the lips like blowing out candles.

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?

Intermittent fetal heart rate auscultation

As your client progresses through the fourth stage of labor (recovery), the nurse makes many assessments. One of these is the assessment of bonding between the parents and the newborn. What is one nursing intervention that promotes maternal-infant bonding?

Kangaroo care

Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply.

Monitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38℃ (100.4℉). Answer questions and encourage verbalization of fears.

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate?

Notify the health care provider about possible meconium.

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?

On the uterine fundus

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

The uterus contracts and squeezes the cord against the fetus.

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions.

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

Turn her or ask her to turn to her side.

Which method does the nurse use to determine fetal presentation, position and attitude?

Utilize Leopold maneuvers

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?

Vaginal examination

The nurse has been monitoring the progression of labor for a primipara. At which time is the nurse most correct to prepare for delivery?

When the fetus is crowning

The client reports having a rupture of membranes that occurred 24 hours ago. When assessing the client, which data is most pertinent? Select all that apply.

Your temperature is 38.3°C (101°F). I am having green-tinged fluid discharge. I am having contractions which are 5 minutes apart. The fetal monitor states that the fetal heart rate is 186 beats/min

Which action is a priority when caring for a woman during the fourth stage of labor?

assessing the uterine fundus

A client is now in the second stage of labor. While doing the assessment, which data should the nurse prioritize?

contraction pattern every 15 minutes

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate

A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?

fetal back

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed

A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply.

frequency duration intensity

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds?

in the woman's lower abdominal quadrant

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

latent active transition

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

latent phase

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

placenta previa

The nurse is admitting a client who has just arrived stating she is in labor. Which fetal assessments will the nurse prioritize on the initial vaginal examination? (Select all that apply.)

presentation position attitude

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

prolonged decelerations

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor?

scalp edema

A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor?

second stage