EAQ- Pregnancy, birth, and uncomplicated postpartum

A pregnant woman is admitted in active labor. What should the nurse instruct her coach to do when the client complains of back pain?

Apply pressure to the sacrum during contractions. Counterpressure helps alleviate some discomfort. This can be provided with a firm massage, a tennis ball, or a rolling pin. Elevating the legs will increase tension on the back and increase discomfort. Panting may lead to hyperventilation, which may result in maternal respiratory alkalosis and fetal acidosis. Kegel exercises do not help relieve back pain; they tone the pelvic musculature.

A pregnant woman tells the nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse which foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend?

Black and pinto beans Enriched bread and pasta Legumes contain large amounts of folate, as do enriched grain products. Beef and fish do not contain adequate amounts of folate. Milk and cheese do not contain adequate amounts of folate; nor does fowl.

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?

Breathe into her cupped hands Dizziness and tingling of the hands are signs of respiratory alkalosis, most likely the result of hyperventilating. Breathing into cupped hands or a paper bag promotes the rebreathing of carbon dioxide. Panting during the next three contractions could cause the client to hyperventilate more. Holding her breath with the next contraction will not improve the client's respiratory alkalosis. Using a fast, deep, or shallow breathing pattern could cause the client to hyperventilate more.

The nurse instructs a pregnant client regarding fetal growth and development. Which statement indicates that the client requires further teaching?

"The fetus gets nutrients from the amniotic fluid." The amniotic fluid provides protection, not nutrition; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. The statements that the fetus keeps growing throughout pregnancy, that it may be underweight if exposed to smoke, and that it gets oxygen from blood in the placenta all indicate that the client understands the teaching.

A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. Which action should the nurse take?

Discontinuing the test because the pattern is within the normal range The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.

A woman in labor hears the primary healthcare provider tell the nurse that the fetal lie is longitudinal. The mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond?

"A vaginal birth is possible." A longitudinal lie means that the fetus is lying parallel to the woman's spine; therefore vaginal birth is possible. A transverse, not longitudinal, lie might indicate that vaginal birth is unlikely, and cesarean birth is anticipated. The fetal lie will influence the labor and the birth of the fetus. A longitudinal lie does not indicate that the labor will be prolonged; however, if the fetal head is in the posterior occiput position, second-stage labor may be prolonged, accompanied by back pain.

A client in labor is admitted to the birthing room. The nurse's assessment reveals that the fetus is at -1 station. Where is the presenting part?

1 cm above the ischial spines Station -1 signifies that the fetal head is 1 cm above the ischial spines and has not reached the vaginal canal. When the fetal head is 1 cm below the ischial spines, it is at station +1. When the fetal head is visible at the vaginal opening, it is at station +4. When the fetal head is level with the ischial spines, it is at station 0.

A client who expected to use the Lamaze technique throughout labor has an emergency cesarean birth. Two days later the client is found crying and tells the nurse that she is extremely disappointed because a cesarean birth was necessary. She asks the nurse why this happened to her. The nurse answers based upon which physiologic response?

An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience. The client's response is appropriate to the situation; she is in the "Why me?" stage of the grieving process as she grieves over the loss of her anticipated birth experience. The client's feelings are unrelated to bonding. The client's statement is not indicative of depression. Self-concept is not specifically affected, although feelings of inadequacy are commonly expressed throughout the grieving process.

A primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the what?

Anterior pituitary gland Hypersecretion of melanocyte-stimulating hormone (MSH) from the anterior pituitary gland causes darkened pigmentations during pregnancy. MSH is not secreted by the adrenal glands, thyroid gland, or posterior pituitary gland.

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. Which nursing action will help relieve this discomfort?

Applying pressure against her sacrum Counterpressure over the sacral area helps relieve the pain caused by the pressure of the fetal head in the posterior position. Although helpful for placental perfusion, positioning the client on her left side is not the best action for reducing pain caused by the pressure of the fetal head in the posterior position. Massaging the abdomen with the fingertips (effleurage) does not relieve the painful pressure in the lower back. The semi-Fowler position causes additional discomfort because the sacrum is inaccessible and counterpressure cannot be applied to the sacral area.

During an emergency birth the fetal head is crowning on the perineum. How should the nurse support the head as it is being delivered?

By distributing the fingers evenly around the head Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from "popping out," which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate.

Which behavior indicates to the nurse that a new mother is in the taking-hold phase?

Calling the baby by name The mother has moved into the taking-hold phase when she takes control and becomes actively involved with her infant and calls the infant by name. She has completed the taking-in phase when her own needs no longer predominate. Talking about the labor and birth occur in the taking-in phase when she has the need to integrate the experience. Touching the baby with her fingertips is the initial early action of the taking-in phase. Being involved with the infant's need to eat and sleep is part of the taking-in phase.

A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next?

Changing the client's position Variable decelerations are usually the result of cord compression; a change of position will relieve the pressure on the cord. Variable decelerations are not related to the mother's blood pressure or to the oxytocin. Preparing the client for an immediate birth is premature; other nursing measures should be tried first.

A client and her partner are working together to achieve an unmedicated birth. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the client to do that will alleviate discomfort during contractions?

Deep-breathe slowly. Slow, deep breathing expands the spaces between the ribs and raises the abdominal muscles, giving the uterus room to expand and preventing painful pressure of the uterus against the abdominal wall. Pelvic rocking is used to relieve pressure from back labor. Panting is used to halt or delay the expulsion of the infant's head before complete dilation has occurred. Patterned, paced breathing is used during the transition phase of the first stage; the client has not yet reached this phase.

What is a priority intervention for the infant undergoing phototherapy?

Exposing as much skin as possible by turning the infant every 2 hours Turning the infant permits optimal skin exposure to the phototherapy lights. The infant's face should not be covered; only the eyes should be covered. Glucose water does not promote excretion of bilirubin in the stools. The supine position would expose only the front of the infant to the lights

A woman who is 28 weeks pregnant calls the clinic to report that she is frightened because she has begun leaking breast milk. What is the best response?

This can be a normal occurrence during pregnancy.

The nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. Which positive sign of pregnancy should the nurse evaluate in this client?

Audible fetal HR The presence of the fetal heartbeat is a positive sign of pregnancy. The feeling of movement is a presumptive sign of pregnancy. An enlarged abdomen is a probable sign of pregnancy. The bluish color of the cervix (Chadwick sign) is caused by pelvic congestion and edema; it is a probable sign of pregnancy.

A woman in labor with her third child is dilated to 7 cm, and the fetal head is at station +1. The client's membranes rupture. What is the nurse's priority intervention?

Check the fetal heart rate while observing the color of the amniotic fluid Fetal well-being is the priority. The fetal heart rate will reflect the fetus's response to the rupture of the membranes, and the color of the amniotic fluid will reveal whether there is meconium staining. Notifying the practitioner is necessary if the nurse's assessments reveal fetal compromise. Although checking the vaginal opening for cord prolapse is important, it is not the priority; the fetal head is engaged at station +1. Although positioning the client on the left side promotes placental perfusion, it is not the priority, and a sterile pad is not needed.

Which prenatal teaching is most applicable for a client who is between 13 and 24 weeks' gestation?

Growth of the fetus, personal hygiene, and nutritional guidance Awareness of the fetus as an individual and the expected changes of pregnancy lead the client to seek information regarding fetal growth, body changes, and nutrition. Information on infant care, travel to the hospital, signs of labor, signs of preeclampsia, and relaxation breathing techniques is appropriate in the last trimester. Interventions for nausea and vomiting, urinary frequency, and anticipated care are appropriate for the first trimester.

A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. Which additional information about the fetus will examination of the amniotic fluid reveal at this time?

Neural tube defect Alpha-fetoprotein in amniotic fluid is increased in the presence of a neural tube defect. Lung maturity cannot be determined until after 35 weeks' gestation. Neither diabetes nor cardiac disorders can be detected with the use of amniocentesis.

The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions?

Push with her glottis open The contractions in the second stage of labor are expulsive in nature; having the client push or bear down with the glottis open will hasten expulsion. Contractions are now intense and the client will be unable to relax; relaxation occurs between contractions. Having the client close her eyes, blow, or pant will prevent pushing and should not be encouraged until the fetal head crowns (+4 station) and a controlled birth is desired.

The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of most concern to the nurse?

Spontaneous rupture of membranes 3 hours ago Rupture of the membranes before intrapartum treatment of GBS increases the chances that infection will ascend into the uterus. GBS infection is a leading cause of neonatal morbidity and mortality. Continued bloody show, cervical dilation of 4 cm, and contractions every 4 minutes are all normal findings for a client in labor.

A nurse is assessing a primigravida who was admitted in early labor. She is at 41 weeks' gestation. Her contractions are irregular, and her cervix is dilated 3 cm. The fetal head is at station 0, and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?

Take a walk around the unit with her. Walking may increase the frequency and strength of the contractions. Although watching TV may be a relaxing activity, it will not help stimulate labor. At this time there is no indication that the client should assume the left-lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.

At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm, and her contractions are occurring every 4 minutes and lasting 45 seconds. What is the likely cause of these late decelerations?

Uteroplacental insufficiency Late decelerations are indicative of uteroplacental insufficiency and, left uncorrected, lead to fetal hypoxia, fetal myocardial depression, or both. The imminence of birth cannot be determined from fetal heart rate decelerations, only from cervical dilation. Birth occurs after the cervix has dilated to 10 cm and the fetus has passed through the birth canal. Nonprogressive labor cannot be determined from fetal heart rate decelerations, only from cervical dilation. Late decelerations are not expected, are not reassuring, and must not be ignored.

On a 6-week postpartum visit a new mother tells the nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach the mother that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for what?

Vitamin C and iron Whole milk does not meet the infant's need for vitamin C and iron. It contains adequate fats; however, the calcium content is 3.5 times that of human milk. The sodium and protein content of whole milk is 3 times that of human milk and unsuitable for an infant of this age.

A Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of what?

7.5 Amniotic fluid changes the color of a Nitrazine strip from yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5, or 6.5 would result in a test strip of yellow, olive yellow, or blue green, respectively.

A client at 8 weeks' gestation tells the nurse that since becoming pregnant, she has not felt like making love with her husband. She is concerned that her husband does not understand. What is the most appropriate response by the nurse?

"A decrease in libido is common during the first trimester of pregnancy." Often the pregnant woman experiences a decrease in sexual desire during the first trimester, probably as a result of nausea and vomiting; if couples are informed about this, they are less likely to become distressed. Calling the situation a problem may cause more anxiety. The client has already stated that the problem began with pregnancy. The client is asking the nurse for information; the client may be unable to tell the nurse. Stating that the client's husband will understand that this feeling is related to the client's pregnancy does not tell the client why this feeling is occurring; furthermore it offers false reassurance.

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what?

Can cause decreased placental perfusion In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true.

The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed?

From the beginning of one contraction to the beginning of the next contraction

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?

Provide the client with comfort measures used for women in labor. The client is experiencing the expected discomforts of labor; the nurse should initiate measures that will promote relaxation. The client is in early first-stage labor; pushing commences during the second stage. Patterned, paced breathing should be used in the transition phase, not the early phase of the first stage of labor. There is no evidence that the client's bleeding is excessive or unexpected and that a transfusion will be needed.

A client at 42 weeks' gestation is scheduled for induction of labor. The nurse begins the induction with a piggyback infusion of 15 units of oxytocin. Which clinical finding requires the nurse to discontinue the oxytocin infusion?

Several late fetal heart rate decelerations that return to baseline after the contraction is over Late decelerations suggest uteroplacental insufficiency, which is an indication that the oxytocin infusion should be stopped. Continuing the infusion may compromise the status of the fetus. Contractions that occur every 3 minutes and last 60 seconds are within acceptable parameters; they require continued monitoring, and the infusion of oxytocin may be continued. An increase in blood pressure from 110/70 to 135/85 mm Hg during the past 30 minutes or rupture of the membranes requires continued monitoring, but does not make it necessary for the infusion of oxytocin to be stopped.

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a third-degree laceration. The client tells the nurse that her perineal area is very painful. What is the physiological finding that is the cause of this pain?

The anal sphincter muscle has been injured. A third-degree laceration extends through the perineal muscles and continues through the anal sphincter muscle. Cutting of the perineal muscles constitutes a second-degree laceration. Trauma to the rectum constitutes a fourth-degree laceration. Damage to superficial muscles is a first-degree laceration.

A nurse is caring for a client during an ultrasonogram. Which parameters does the nurse expect to be used in the determination of pregnancy dates?

crown-to-rump measurement until 11 weeks. Crown-to-rump measurement is used to determine the age of the embryo until 11 weeks. Occipital frontal diameter is not an ultrasound measurement used at term. Biparietal diameter at term will be approximately 9.8 cm. Diagonal conjugate is not used as an ultrasound measurement; it is the estimated size of the maternal pelvic outlet. The actual size of the pelvis as it relates to fetal size is best determined with ultrasonography

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record?

First The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.

A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours after delivery. How does the nurse determine that the uterus is demonstrating appropriate involution?

The amount of lochia rubra is moderate Red, distinctly blood-tinged vaginal flow ( lochia rubra) is expected during the first few postpartum days and indicates that involution is progressing as it should. Clots indicate uterine atony, which prevents involution of the uterus. The status of the episiotomy is unrelated to the status of the uterus. Uterine cramps during breastfeeding are evidence that the uterus is undergoing appropriate involution.

During a childbirth class the nurse determines that the women understand how to use effleurage correctly when they are observed doing what?

Massaging their abdomens gently with their fingertips Effleurage is a gentle massage of the abdomen that is effective during the first stage of labor because it distracts the client from the discomfort of the contractions. Rocking gently on the knees, known as the pelvic rock, is used during pregnancy to relieve backache. Practicing panting to avoid pushing during labor is a technique of breathing. Taking deep breaths before imagined contractions is also a technique of breathing.

A pregnant client is asking the nurse when she will gain the greatest amount of weight during the pregnancy. At which time during prenatal development should the nurse tell the client to expect the greatest fetal and maternal weight gain?

The third trimester is the period in which the fetus stores deposits of fat. There is growth, but fat deposition does not occur in the second trimester. The first 8 weeks is the period of organogenesis, when cells differentiate into major organ systems. The implantation period is the period of the blastocyst, when initial cell division takes place.

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the priority nursing action?

Notify the healthcare provider Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.

After a client has been in labor for 6 hours at home, and she is admitted to the birthing room. The client is dilated 5 cm and at -1 station. In the next hour her contractions gradually become irregular and are more uncomfortable. Which possibility should the nurse consider first?

The client has a full bladder. A full bladder can impede the forces of labor, and so it must be emptied before any further assessment. The client's cervix is dilating, and therefore she is in true, not false, labor. Before the possibility of uterine dysfunction is considered, the client's bladder should be emptied to relieve the pressure of the bladder on the uterus; the client should then be observed to determine whether regular contractions have resumed. The existence of a breech presentation should have been established during the admission examination.

A nurse performs Leopold maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is what?

LOA The fetus is in a left occiput anterior (LOA) position because the buttock (firm mass) is in the fundus, the back is on the left, the small parts are on the right, and the head is flexed, indicating an anterior occiput. The right occiput anterior (ROA) position is indicated by the presence of the back on the right side and the cephalic prominence on the left side; the occiput is anterior. The left mentum posterior (LMP) position is marked by cephalic prominence. The back is on the same side, indicating an extended head and chin presentation. In the right mentum posterior (RMP) position, the back and cephalic prominence are situated on the same side (right), indicating an extended head and chin presentation.

The nurse determines that a client's placenta has separated during the third stage of labor. Which clinical finding supports the nurse's conclusion?

A gush of blood There is a gush of blood when the placenta separates from the uterine wall, before the physiologic clamping of the vessels at the placental site occurs. The uterus contracts and becomes firm, not boggy, when the placenta separates because of the influence of endogenous oxytocin. The uterus appears to increase, not decrease, in size when the placenta separates. The uterus changes from round to an egg shape as the placenta moves into the lower uterine segment. The blood pressure returns to prenatal status shortly after birth; the decrease is gradual and unrelated to placental separation.

While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action?

Asking the client when she last changed the perineal pad The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported or recorded without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion.

A 37-year-old woman agrees to have a prenatal test done in order to diagnose fetal defects. There is a history of Down syndrome in her family. Which invasive prenatal test provides the earliest diagnosis and rapid test results?

Chorionic villus sampling Chorionic villus sampling may be performed between 10 and 12 weeks' gestation. The nonstress test, which is not invasive, is a technique used for antepartum evaluation of the fetus; it does not reveal fetal defects. Amniocentesis may be performed after 14 weeks' gestation, when sufficient amniotic fluid is available. Direct access to the fetal circulation with percutaneous umbilical blood sampling may be performed during the second and third trimesters.

A client gives birth to an 8-lb (3529-g) baby. Ten minutes after the birth, the placenta has not yet separated. What is the nurse's priority action at this time?

Continuing to assess the client for signs of separation The third stage of labor (from birth to expulsion of the placenta) may last as long as 30 minutes and still be within acceptable limits. Applying fundal pressure is an outmoded procedure that can cause eversion of the uterus. Oxytocin is not administered before the expulsion of the placenta. It is too early to seek consent for manual removal at this time.

The nurse explains to a woman in her twenty-fourth week of pregnancy that absorption of medications taken orally during pregnancy may be altered as a result of what?

Delayed gastrointestinal emptying Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and of the intestines laterally and posteriorly; absorption of some medications, vitamins, and minerals may be increased. The glomerular filtration rate increases during pregnancy and is unrelated to the absorption of medications. Developing fetal-placental circulation is unrelated to the absorption of medications. The amount of gastric secretion is somewhat lower in the first and second trimesters but increases dramatically in the third trimester; neither decreased nor increased gastric secretions affect medication absorption.

During a routine prenatal visit, a client tells the nurse that she often gets muscle weakness and leg cramps. What condition does the nurse suspect, and what suggestion is made to correct the problem?

Hypocalcemia; increase her intake of milk The most likely cause is a disturbance in the ratio of calcium to phosphorus, with the amount of serum calcium reduced and the serum phosphorus increased; milk and other dairy products are excellent sources of calcium. Leg cramps are related to hypocalcemia, not to hypercalcemia. An increased potassium level manifests as muscle weakness. A low potassium level is evidenced by fatigue and muscle weakness.

A client is admitted to the birthing room in active labor. She is gravida 4, para 3. When she is at 8 cm of dilation, her membranes rupture spontaneously. What should the nurse do after assessing fetal well-being?

Perform a vaginal exam. Because the client is a multigravida, the fetal head may not have engaged in the pelvis. The umbilical cord may prolapse and become compressed as the fetal head descends; immediate intervention is required if the cord has prolapsed. More data are needed before the practitioner is notified. After it is determined that the umbilical cord has not prolapsed and the fetus' heart rate is within expected limits, documentation may be performed. After it is determined that the umbilical cord has not prolapsed, the client's bedding may be changed.

A pregnant client at 37 weeks' gestation is taught the signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report what?

Leakage of fluid from the vagina Leakage may indicate rupture of the amniotic membranes; the client is at risk for an ascending infection from the vagina if birth does not occur within 24 hours or if early treatment is not instituted. Lower back pain is a common discomfort of pregnancy because the enlarged uterus causes a shift in the client's center of gravity. Leukorrhea is common during pregnancy because of increased vascularity of the cervix and increased production of mucus. Preparatory (Braxton Hicks) contractions occur at irregular intervals throughout pregnancy; they become stronger after the 28th week of gestation.

A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. Which breathing pattern should the nurse instruct the patient to adopt?

Pant and then exhale through the mouth with pursed lips The client cannot bear down when panting and exhaling. The objective is to control the birth and prevent injury to both mother and newborn. The nurse should place a hand on the perineum to apply gentle pressure and then support the head as it emerges. Slow breaths enhance relaxation; this type of breathing is impossible to achieve when the fetal head is crowning. Holding the breath and pushing will result in a precipitous birth that could cause injury to both mother and newborn. Breathing faster than usual and taking long cleansing breaths are impossible to achieve when the fetal head is crowning

The nurse is caring for a client in the transition phase of labor. Which breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation?

Panting-blowing pattern The client should use a panting or blowing pattern to overcome the premature urge to push. Expulsion breathing should not be used at this time because the cervix is not fully dilated and cervical edema and lacerations may occur. A slow-paced pattern or shallow-chest pattern is ineffective during the transition phase of labor; these patterns are used during early labor.

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, "I can't take this a minute longer." What does this behavior indicate to the nurse caring for her?

She is entering the transition phase of labor. The contractions become stronger, last longer, and occur erratically during the transition phase; the intervals between contractions become shorter than the contractions themselves; the client needs to apply a great deal of concentration and effort to pace her breathing with each contraction. Even clients who have been adequately prepared will experience these behaviors during the transition phase of the first stage of labor. Administration of an analgesic at this time may reduce the effectiveness of labor and depress the fetus. There is no indication that the contractions are hypertonic.

An internal fetal monitor is applied while a client is in labor. What should the nurse explain to the client regarding positioning while the monitor is in place?

The most comfortable position may be assumed. Because electrodes are placed internally (on the fetal scalp, not on the mother's abdomen), position does not affect the monitor. Although the supine position does not affect the monitor, it should be discouraged because the pressure of the gravid uterus inhibits venous return, leading to reduced cardiac output. The side-lying position is recommended because it promotes maternal-fetal circulation. It is not the position but the internal placement of electrodes on the fetal scalp that ensures accurate monitoring. Constant monitoring provides continuous ongoing assessment of fetal status; there is no reason to detach the leads.

Which information should the nurse include in the discharge teaching of a postpartum client?

The prenatal Kegel tightening exercises should be continued. Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.