Chapter 14 Labor and birth
Which of the following practices would not be included in a physiologic birth?
early induction of labor <39 weeks gestation
Baseline variability represents the interplay between the ________ and sympathetic nervous system
parasympathetic
When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every:
15 to 30 minutes
A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?
Assess the fetal heart rate The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes.
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?
Change the clients position The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.
A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. which of the following actions should the nurse include in the plan of care?
Check the cervix prior to analgesic administration Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn
The _______ spines serve as landmarks for estimating the descent of the fetal presenting part and have been designated as zero station
Ischial
a nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is " not really sure if she is in labor or not" which of the following should the nurse recognize as a sign of true labor?
changes in the cervix Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. the nurse should suspect a problem with the umbillical cord when she observes which of the following?
variable decelerations Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus
A nurse is admitting a client who is at 36 weeks gestation and has painless bright red vaginal bleeding. the nurse should recognize this finding as an indication of?
placenta previa!!!!!!!
A nurse is caring for a client during a nonstess test (NST). At the end of 30 MIN period of observation, the nurse notes the following findings: the fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15/min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. which of the following interpretations of these findings should the nurse make?
A nonreactive test
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following should the nurse report to the provider?
Contractions lasting longer than 90 seconds A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider
When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? a. Hold your breath and push through entire contraction. b. Use chest-breathing with the contraction. c. Pant and blow during each contraction. d. Instruct her to wait until she feels the urge to push.
D. insruct her to wait until she feels the urge to push
The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate?
Document this as indicating a normal pattern
A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. which of the following actions should the nurse implement with this client?
Encourage the client to empty her bladder every 2 hr A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhag
If the nitrazine test is inconclusive, an additional test called the _____test, can be used to confirm rupture of membranes
Fern
A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (select all that apply)
Fetal breathing Fetal motion Amniotic fluid volume A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume
A nurse in a providers office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
Hypertension Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.
a nurse is caring for a client who is gravida3, para2, and is in active labor. The fetal head is at 3+ station after a vaginal exam. Which of the following actions should the nurse take?
Observe for crowning In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent
A nurse is caring for a client who is having a non stress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform ?
Offer the client a snack of orange juice and crackers
a nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. which of the following is the correct interpretation of this clincal finding?
The lowermost portion of the fetus is at the level of the ischial spines The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client's ischial spines. Levels above the ischial spines are negative values: -1, -2, -3. Levels below the ischial spines are positive values: +1, +2, +3
A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examine the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
Two arteries and one vein The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta
During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern?
Uterine fundus palpated to the right of the umbilicus
the nurse reviews the prenatal record to identify risk factors that may contribute to a decrease in ________circulation during pregnancy and/or labor
Uteroplacental
Fetal _______ are transitory increases in the FHR above baseline that are associated with sympathetic nervous stimulation
accelerations
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurses priority?
blood pressure 80/56 When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death
A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy red vaginal bleeding. the bleeding started spontaneosly in the morning and is not accompanied by contractions. the client is not in distress and she states that she can "feel the baby moving" An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following?
location of placenta MY ANSWER Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is
A nurse is caring for a client who is in labor. which of the following nursing actions reflects application of the gate control theory of pain?
massage the clients back The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client's back focuses on neuromuscular and cognitive changes
A nurse is caring for a client who is at 36 weeks of gestation and who has suspected placenta previa. Which of the following findings support this diagnosis
painless red vaginal bleeding Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester
A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?
" I will have to lie on my back during the test" The client is placed in a Semi-Fowler's position with one hip slightly elevated to promote uterine perfusion and prevent supine hypotension as a result of the uterus compressing the maternal vena cava
A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
"This could result in profound bleeding" "Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.
A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?
"This test requires the presence of amniotic fluid" Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation
A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the clients oral temperature is 38.9 (102). Besides notifying the provider, which of the following is an appropriate nursing action?
Assess the odor of the amniotic fluid Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid
When managing a clients pain during labor, nurses should:
Support the clients decisions and requests
A nurse on the labor and delivery unit is caring for a client following a vaginal exam by the provider which is documented as -1. which of the following interpretation of this finding should the nurse make?
the presenting part is 1 cm above the ischial spines Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.
The _________is placed over the uterine fundus in the area of greatest contractility to electronically monitor uterine contractions
tocotransducer
By the end of the second stage of labor, the nurse would expect which of the following events? The
fetus is born and on the mothers chest
if the woman is a diabetic, it is crucial to alert the newborn nursery of potential _________in the newborn
hypoglycemia
A nurse in a hospital is caring for a client who is at 38 weeks of gestation an has a large amount of painless, bright red vaginal bleeding. The client is placed on fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The clients vital signs are: blood pressure 98/52. heart rate 118/min, resp rate 24/min, and temp 36.4 (97.6). which of the following is the priority nursing action?
initiate IV access Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.
A nurse is caring for a client who is in the first stage of labor and is using a pattern paced breathing. the client says she feels lightheaded and her fingers are tingling. which of the following actions should the nurse take?
Assist the client to breathe into a paper bag This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion
The nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the clients blood pressure reading as 82/52 mm hg. Which of the following nursing interventions should the nurse perform?
Assist the client to turn onto her side Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify
Fetal position is persistent occiput posterior The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station and the clients amniotic membranes are intact. the client suddenly states that she needs to push. which of the following actions should the nurse take?
Have the client pant during the next contraction Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.
A nurse in a providers office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why shes is having an ultrasound prior to the procedure. Which of the following is an appropriate response byt the nurse?
It assists in identifying the location of the placenta and fetus Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.
A nurse is caring for a client who is in labor and has an external fetal monitor. the nurse observes late
MY ANSWER The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.
A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?
Obtain a 30 minute electronic fetal monitoring (EFM) strip prior to induction The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients blood pressure is 80/40 and the fetal heart rate is 140. Which of the following is the priority nursing action?
Place the client in a lateral position Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm hg. Which of the following is the priority action for the nurse to take?
Postion the client with one hip elevated Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess
A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. which of the following interpretations of this finding should the nurse make?
There is no evidence of uteroplacental insufficiency A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations
A nurse is caring for a client who is in active labor when the clients membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?
Turn the client onto her side When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to turn the client onto her left side. Late decelerations indicate that the client might have uteroplacental insufficiency, maternal hypotension, uterine tachysystole form oxytocin administration, or several other complicating factors. The client might be exerting pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply
A nurse is caring for a client who is in the first stage of labor, Undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitoring strip. Which of the following is a correct interpretation of this finding?
Variable decelerations are due to umbilical cord compression Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.
A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. which of the following is the priority nursing action?
apply an external fetal monitor Based on Maslow's hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress
_________describes the irregular variations or absence of fetal heart rate due to erroneous causes on the fetal monitor record
artifact
A nurse is caring for a client who is to undergo an amniotomy. which of the followinng is the priority nursing action following this procedure?
assess the fetal heart rate pattern MY ANSWER Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent deliver
____ comfort measures are usually simple, safe, effective and inexpensive to use
non pharmalogical
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring the nurse observed that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. which of the following actions should the nurse take first?
place client in lateral position This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?
position the client on her side Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.
the primary power of labor is/are____ contractions, which are involuntary.
uterine
A nurse in the ER is admitting a client who is at 40 weeks of gestation has ruptured membranes and the nurse observes the newborns head is crowning. the client tells the nurse she wants to push. which of the following statments should the nurse make?
" you should try to pant as the delivery proceeds" Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head.
A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse caring for her suspects placenta previa. which of the following is an appropriate nurse action?
A cesarean birth is indicated for all clients who have a confirmed placenta previa.
A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?
A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache These findings indicate that the client's condition is worsening and are signs of severe preeclampsia. They should be reported to the provider immediately. Other manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision, hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant pain