Chapter 14-Nursing Management During Labor and Birth

The nurse is providing preoperative care for a client who will undergo a cesarean section. The nurse should

confirm that consent has been provided by the client.

A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure?

to prevent supine hypotension syndrome

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

acupressure

The nurse assesses her client and notes that the fetus is at +1 station. The nurse interprets +1 station as indicating that the fetal presenting part is at

1cm below the ischial spine

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

Assess fetal heart rate for fetal safety.

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

Dilation of cervix

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents?

FHR fluctuates from 6-25 beats per minute.

Which of the following supports why a preterm fetus usually is more affected by medication given at birth than a full-term fetus?

Inability of the immature liver to metabolize or inactivate drugs

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?

Provide care under the supervision of an RN.

The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize?

Take blood pressure and determine if clonus or edema are present.

The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?

This is a technique to prevent the painful stimuli from entering the brain.

A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal?

clear

A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first?

determine if the client is in true or false labor.

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 15min

In providing culturally competent care to a laboring woman, which is a priority?

identify how the client expresses labor pain.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

palpate the mothers radial pulse at the same time

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate

During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective?

the patient is not requesting pain medication

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign?

the urge to push occurs

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

assess amount of cervical dilation

The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which technique during labor?

attention focusing

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?

fetal status

A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply -fetal bradycardia -fetal tachycardia -sinusoidal pattern -recurrent late decelerations

-fetal bradycardia -sinusoidal pattern -recurrent late decelerations

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

6.5

The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?

Fear of pain during labor

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?

Neonatal depression is possible.

The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?

Pain originates from the cervix and lower uterine segment.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?

acme

The nurse is assessing a laboring client and notes: 5 cm dilated, 80% effaced, zero station, contractions every 2 to 3 minutes, lasting 50 seconds, becoming increasingly uncomfortable, and apprehensive but appropriate and focused on breathing and relaxation. The nurse determines which nursing diagnosis is most appropriate for this client?

acute pain related to uterine contractions

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of O2 mask

A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action?

ambulation ad lib

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?

anxiety can slow down labor and decrease oxygen to the fetus.

A client is now in the second stage of labor. While doing the assessment, the nurse would gather what data at this time?

contraction pattern every 15min.

As a woman enters the second stage of labor, which would the nurse expect to assess?

feelings of being frightened by the change in contractions

When teaching the pregnant patient about self-medicating for pain during labor, why did the nurse instruct the patient to avoid taking acetylsalicylic acid?

interference with blood coagulation with increased risk of bleeding in mother or infant.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

it distracts you from the sensations of pain.

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?

practicing effleurage on the abdomen

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

prolonged decelerations