Chapter 16
How to tell whether the conractions are true contractions or Braxton Hicks contractions Characteristics of true contractions
-begin irregularly but become regular and predictable -increase in duration, frequency, and intensity -felt first in lower back and sweep around to the abdomen in a wave.
A woman entering her third trimester, should gain how much weight?
1 lb/ week
Which intervention would be least effective in caring for a woman who is in the transition phase of labor? 1. encouraging the woman to ambulate 2. focus on one contraction at a time 3. breath with contractions 4. provide one-to-one support
1. encourage the woman to ambulate **contractions at this point are strong and frequent and there is an urge to bear down that makes ambulating difficult. ambulating is beneficial during and early and possibly even active labor.
Six Major concepts that make labor and birth as natural as possible
1. labor should begin on its own, not be artificially induced 2. women should be able to move about freely throughout the labor, not confined to bed 3. women should receive continuous support from a caring other during labor 4. no interventions such as IV fluid should be used routinely; 5. women should be allowed to assume a nonsupine position such as upright and side-lying for birth 6. mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding.
A nurse is conducting an in-service program for staff nurses working the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which meaure? 1. encouraging the woman to use relaxation techniquese 2. allowing the woman time to be alone 3. notify patient about info about procedures
2. Allowing the woman time to be alone ** positive support, not being alone, promotes a positive birth experience Being alone can increase anxiety and fear, decreasing the ability to cope
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? 1. Rubbing the legs 2. Massaging lower back 3. placing a wedge under the hips 4. providing a paper bag to breathe in
3. placing a wedge under the hips. **due to the lithotomy position, placing a wedge under the hips is correct to avoid supine hypotension.
The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize?
Assess return of sensory and motor functions to the lower extremities to ambulate the mother ** The mother will not be able to walk for sometime (until the medication wears off) Do not elevate legs--> the goal is to maintain normal circulation
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.
The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?
Continue with the admission assessment--> establish a baseline and determine her status --> this can include asking personal questions, inappropriate to ask in front of the doula.
A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client?
The cervix takes around 12 to 16 hours to dilate during the first pregnancy
The nurse is caring for a client at 39 weeks gestation and whose fetal station is noted as a 0. The nurse is correct to document what about fetal station position?
The fetus is in the true pelvis and engaged. 0: fetus is at the level os the ischial spines and said to be engaged If the fetus is floating high in the pelvis, its station is noted as a negative number Descending into the pelvis or birth canal is a positive number.
The client in labor at 3cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?
This may prolong labor and increase complications **Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. --> offer nonpharmacologic alternatiives until she is in active labor.
A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible
Women should be able to move about freely through labor
A woman's amniotic fluid is noted to be cloudy, the nurse interprets this finding as
a possible infection
vertex presentation
a type of cephalic presentation presenting part is the occiput
the first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care?
a woman may spend time thiinking about what is happening to her **Women need a support person with them during all stages of labor
The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording
acceleration of at least 15 bpm for 15 seconds
A nurse is admitting a client who presents in active labor at 41 weeks gestation. The nurse prepares for the possibility of a cesarean delivery after noting the client has which type of pelvis documented?
android *Android pelvis is considered the male-shaped pelvis and is a funnel-shape, or smaller dimensions in the lower outlet than the upper level. --> it is difficult for a large fetus to pass through and it may require a c-section.
brow presentation
brow or sinciput is presenting
The nurse is teaching a non-English speaker primigravida about the most common type of fetal presentation. How will the nurse present this info.
cephalic presentation using preprinted materials in her language *The most common presentation type is cephalic presentation.
The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?
continuous labor support. ** continuous labor support by a caring nurse or doula can help decrease a woman's anxiety during labor.
A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method?
counterirritation stimulation blocks pain from traveling to the spinal cord
Touch and massage methods that can be helpful during labor
counterpressure effleurage
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 **The best determination of effective contractions is dilation of the cervix.
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. the nurse identifies this technique as
effleurage
transcutaneous electrical nerve stimulation (TENS) reduce pain by which mechanism
electrical impulses are created that interfere with nerve transmission
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. **lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction
The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents the finding as:
frequency
which nursing action is required before a client in labor receives an epidural?
giving a fluid bolus of 500mL
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
To give birth to her infant, a woman is asked to push with contraction. Which pushing technique is the most effective and safest
head elevated, grasping knees, breathing out ** be sure woman does not hold her breath--> it puts pressure on the vena cava, reducing blood return
A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements: "transverse lie is the same as when the fetal buttocks present to the birth canal"
in most term pregnancies the fetus presents head down In a breech presentation, the fetal buttocks, feet, or both present to the birth canal Transverse is the same as should presentation
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant *The best position to auscultate fetal heart tones is on the fetus back. In this position the best place for the FHR monitor is on the left lower quadrant
A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several question, the nurse explains this is probably due to:
lightening **lightening occurs when the fetal presenting part beings to descend into the maternal pelvis. The uterus lowers and moves into a more anterior position In primiparas--> lightening can occur two weeks or more before labor begins. multiparas: it may not occur until labor.
The nurse is caring for a patient in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this patient's discomfort?
massage the lower back **occiput position: the fetal head rotates against the sacrum, the patient may experience pressure and pain the lower back because of sacral nerve compression.
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine **common opioid used during labor and birth
Assessment reveals that the fetus of a client in labor is in the vertex presentation. the nurse determines that which part is presenting
occiput
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 mother's radial pulse at the same time
crowning
point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed.
molding
process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.
What is the primary role of the LPN/LVN members of the team
provide care under the supervision of an RN
A nurse is coaching a woman during the second stage of labor. which action should the nurse encourage the client to do at this time?
push with contractions and rest between them
A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?
risk for infection
Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?
rupture of amniotic membranes
A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?
support the client's decision and call the obstetrician
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 **The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression
gynecoid pelvis
typical female pelvis -most favorable for birth -rounded shape, allows the fetus room to pass through -do not expect the labor to take a long time, and no additional measure needed
dilation
widening, stretching, expanding of the cervical canal from a few mm to approx. 10cm.
A primigravida client at 38 weeks gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." How should the nurse respond
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks"
The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?
Assess fetal heart rate *After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration After birth, there may be a decrease in alertness.
A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which phases?
Latent, active, transition
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?" How should the nurse explain?
"It distracts your brain from the sensations of pain"
Acceptable FHR
110 to 160bpm
at midpoint during pregnancy, you review beginning signs of labor with a patient. One of the beginning signs of labor you would review is
A sudden gush of clear fluid from the vagina
A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?
Advise the patient to hold out a bit longer, if possible, before administration of the drug, to preventing slowing of labor
A client has just received combined spinal epidural. Which nursing assessment should be performed first?
Assess Vital Signs ** The most common side effect of spinal and epidural anesthesia is hypotension **hypotension can lead to fetal bradycardia, decelerations, or fetal distress
A primigravida client at 39 weeks gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize
ask the woman to describe why she believes that she is in labor
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
Doula
birth coach--> provide one on one support in labor and through birth Doula does not take place of a nurse or client's partner, but is there to assist in the process.
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A) +2 station B) 0 station C) -2 station D) Crowning
c)- 2 station
A nurse is caring for a client adminisitered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?
continue to massage the client's fundus
Cardinal movements of labor
descent flexion internal rotation extension external rotation expulsion
A 39 week gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse FIRST do?
determine if the client is in true or false labor.
The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed?
determining: -Lie - position of the fetus -presentation of the fetus
Massage is an effective nonpharmacologic technique that can help to decrease pain during labor. The nurse explains that massage achieves its effect by which mechanism
increasing the release of endorphins
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 1. frequency 2. activity of fetus 3. duration 4. intensity 5. status of membranes
intensity, frequency and duration
platypelloid pelvis
least common type, pelvic cavity shallow, makes it difficult for fetus to descend through mid-pelvis, labor prognosis poor, leads to C-section
footlong breech
one or both legs are presenting
Fetal lie
refers to the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. 3 types of lies: -longitudinal -oblique -transverse
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?
respiratory rate * The nurse must monitor for respiratory depression.
transverse presentation
same as shoulder presentation --> babies shoulders present
shoulder presentation
shoulders are presenting
effacement
softening, thinning, and shortening of the cervical canal
which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?
the mother may have difficulty working effectively with contractions
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 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?
these methods are a technique to prevent the painful stimuli from entering the brain
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 **when membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration. which might indicate cord compression secondary to cord prolapse
A nurse is assisting with the birth of a newborn. The fetal head has just emerged. Which action would be performed next?
checking for the cord around the neck
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in LOA position. The nurse anticipates noting which finding when the membranes rupture
clear to straw-colored fluid * the infant is in the correct position and the client has been in labor--> expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid.
The nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?
effacement
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?
take no extra measures; prepare for a standard labor
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 *In the hypoxic fetus, the pH will fall below 7.2, which s indicative of fetal distress
A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor
restoration of blood flow to uterus and placenta
Contractions
- shortening of the upper uterine segment -reduction in length of cervical canal -effacement and dilation of the cervix
frank breech
-Buttocks present first with both legs extended up toward the face. -Hips are flexed, and the knees are extended
A nursing instructor is teaching students about the labor and delivery process:
-anxiety can slow down the labor process - Nurses can influence birth outcomes in a positive way -continuous labor support by a caring nurse results in better birth outcomes
A client received epidural anesthesia and developed a postdural spinal headache. What should the nurse know about a postdural spinal headache?
Client should be encouraged to drink plenty of fluids *Treatment of postdural spinal headache is hydration --sitting upright increases the severity of the headache --without treatment it can last days to weeks
A patient states: "the baby is coming" and "I feel like I have to have a bowel movement" It is likely the woman is in which stage of labor
Second stage
A 19-year old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:
The buttocks are presenting first with both legs extended up towards the face
The practical nursing is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the practical nurse do first?
assess and reposition the woman **Due to maternal movement the fetal heart monitor may become dislodged and not provide accurate tracings.
A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse use?
longitudinal **
5 p's of labor
passageway, passenger, position, powers, psych
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 client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?
use a fist to apply counter pressure to the lower back
A client in labor is anxious about having an IV infusion. Following insertion of the IV line, which nursing action is best?
use distraction therapy **distraction therapy helps the client to focus her attention on the birthing process.
Epidural agent
-spread through the spinal canal -may produce hypotensive crisis -may produce fetal bradycardia
A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 AM and notes the following; moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?
10:30 AM ** assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns.
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first? 1. instruct the client to do slow-paced breathing 2. assist the client in ambulating 3. help the client change positions 4. assess for labor progression
Assess for labor progression ** performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the client experience a reduction in pain. --> best first step is to assess for labor progress before assisting her otherwise.
When describing the stages of labor to a pregnant woman, what would the nurse identify as the major change occurring during the first phase?
cervical dilation
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process?
crowning
The nurse is assessing a pregnant client at 37 weeks gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nursee should point out which event has occurred?
engagement **the movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement for the fetus in preparation for the spontaneous vaginal delivery.
Effleurage
light, stroking, superficial touch of the abdomen in rhythm with breathing during contraction
When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture?
meconium-stained amniotic fluid
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?
relaxin **As the pregnancy progresses, the hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the pelvis for birth.
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 **signs that the placenta is separating --> firmly contracting uterus --> a change in uterine shape from discoid to globular ovoid --> a sudden gush of dark blood from the vaginal opening --> lengthening of the umbilical cord protruding from the vagina.
full breech
the fetus sits cross-legged above the cervix
Lamaze birth
through concentration, clients can learn to use controlled breathing to reduce pain.
The nurse has been monitoring the progression of labor for primipara. At which time is the nurse most correct to prepare for delivery?
when the fetus is crowning ** prepare for delivery when the perineum is bulging or the fetus is crowning in the primipara. Preparing for delivery: -breaking the bed to form the delivery area
